THE CONUNDRUM OF LOWER GASTROINTESTINAL BLEEDING
Section snippets
EVALUATION OF THE ACTIVELY BLEEDING PATIENT
The specific sequence of diagnostic studies is determined primarily by the clinical status of the patient and by the rate and pattern of bleeding. In the setting of sudden onset of massive hematochezia, the history should include questions about dyspepsia, use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), as well as about abdominal and anorectal complaints, such as anal bleeding, pain, or protrusion; change in bowel habits; or similar past episodes of hematochezia. Resuscitation
Technetium-Labeled Red Blood Cell Scanning
If no immediately obvious source of bleeding is found by nasogastric aspiration and by anorectal examination, and if the bleeding is thought to be ongoing, a Tc-labeled RBC scan is a noninvasive but potentially very helpful study that can be done rapidly and often gives a general idea of the site of the bleeding. This study is useful only for localization of bleeding sites and not for making a specific diagnosis; it has no therapeutic benefit, except to direct further intervention. False
Diverticular Bleeding
The average age for people with lower GI bleeding is about 60 years, and by this age virtually everyone has developed colonic diverticula. The cause is currently thought to be increased segmental intraluminal pressure, which causes a segment of mucosa to extrude at the relatively weaker areas of the muscularis propria, which are the sites of the penetrating arterial vasa recta. These pseudodiverticula then lie immediately adjacent to the vasa recta. It is not known what initiates bleeding in
THE BLEEDING PATIENT WITHOUT SPECIFIC LOCALIZATION
It is occasionally necessary to contemplate surgical intervention without a clear idea of the specific site of bleeding. Reasons for this are generally either that the patient is believed to be hemodynamically too unstable to permit Tc-labeled RBC scanning, arteriography, or other diagnostic studies, or that these studies are not available or do not disclose the site of bleeding, or because of repeated episodes of severe bleeding on the same or subsequent hospital admissions. Exploratory
THE PATIENT WITH RECURRENT SELF-LIMITED BLEEDING
In about 5% of patients with GI bleeding, standard evaluation fails to reveal the source of the bleeding.60 In addition to repeated examination with colonoscopy and esophagoduodenoscopy, additional studies are potentially helpful in finding small bowel sources of bleeding. Small-bowel follow-through examination has the advantages that it requires minimal preparation, is relatively inexpensive, and is easily tolerated. Enteroclysis, a double-contrast technique of examination of the small bowel,
SUMMARY
Acute massive hematochezia provides one of the greatest diagnostic and therapeutic challenges to the physician. Although most patients stop bleeding spontaneously and further evaluation can be carried on with less urgency, 10% to 15% require urgent diagnostic and therapeutic procedures. Clearly, the least invasive effective solution to the bleeding problem is generally the best, although in some cases, emergency undirected surgery may be necessary. Subtotal colectomy can be done with acceptable
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Cited by (58)
Planar scintigraphic imaging of the gastrointestinal tract in clinical practice
2012, Seminars in Nuclear MedicineCitation Excerpt :Before the era of computer processing, the Tc-99m RBC, GI bleeding scans used a series of static image acquisitions accomplished at 5 to 10-minute intervals. Because approximately 3-5 mL of radiolabeled blood must be present to produce an interpretable signal on the nuclear scan,35 relatively prolonged imaging intervals could theoretically fail to detect intermittent bleeding events because of dilution of the extravasated radiolabeled blood within the GI tract. Also, a detected focal region of increased activity may incorrectly assign the location of the bleed, given the potential for both rapid anterograde and retrograde movement.
Acute Lower Gastrointestinal Hemorrhage: Minimally Invasive Management with Microcatheter Embolization
2008, Journal of Vascular and Interventional RadiologyDetection of gastrointestinal bleeding by using multislice computed tomography-acute and chronic hemorrhages
2008, Clinical ImagingCitation Excerpt :Diapedesis bleedings are seldom. More often, bleedings are caused by erosions of peptic or neoplastic origin [2]. Acute gastrointestinal hemorrhage is an emergency situation.
Gastrointestinal Hemorrhage
2007, Textbook of Gastrointestinal RadiologyMesenteric angiography for the localization and treatment of acute lower gastrointestinal bleeding
2008, Canadian Journal of Surgery
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