Disorders   of   the   Gastrointestinal   System Orlando Regional Medical Center 2008
 
Intestinal   Obstructions
Intestinal Obstruction <ul><li>Blockage of intestinal tract that inhibits passage of fluid, gas, feces </li></ul><ul><li>C...
Intestinal Obstructions <ul><li>Paralytic Ileus  or “silent bowel” is most often seen after abdominal surgery & anesthesia...
Sigmoid Volvulus <ul><li>Sigmoid Volvulus  (twisting): usually seen in the older individual with a history of straining at...
Sigmoid Volvulus
Intussusception <ul><li>only 5-15 % occurrence in adults </li></ul><ul><li>s/s colicky abd pain, nausea, vomit, diarrhea, ...
Intussusception
Small Bowel Obstruction <ul><li>“ Never let the sun rise or set on a small bowel obstruction.” </li></ul><ul><li>(surgical...
Small  Bowel Obstruction <ul><li>Causes of SBO: </li></ul><ul><li>Adhesions  (post-surgical, post-inflammatory) </li></ul>...
Small  Bowel Obstruction <ul><li>Causes of small bowel obstruction include: </li></ul><ul><li>Adhesions  from previous abd...
Small  Bowel Obstruction <ul><li>Signs & Symptoms of Small Bowel Obstruction: </li></ul><ul><li>  Abdominal pain </li><...
Small  Bowel Obstruction <ul><li>The essentials: </li></ul><ul><li>* Common, may or may not require surgery </li></ul><ul>...
Small  Bowel Obstruction
Large  Bowel Obstruction <ul><li>A large bowel obstruction is an emergency condition that requires early & prompt surgical...
Large   Bowel Obstruction <ul><li>Causes of large bowel obstruction include: </li></ul><ul><li>Neoplasms  </li></ul><ul><l...
Large   Bowel Obstruction <ul><li>Signs & Symptoms of Large Bowel Obstruction: </li></ul><ul><li>  Abdominal pain </li>...
Large  Bowel Obstruction
When to Operate? <ul><li>Incarcerated or strangulated hernia </li></ul><ul><li>Peritonitis </li></ul><ul><li>Pneumoperiton...
Gastrointestinal Disorders
Diarrhea <ul><li>Causes of Diarrhea </li></ul><ul><ul><li>Osmotic :  the presence of nonabsorbable substances in the intes...
Intestinal Ulcers
Peptic Ulcer Disease <ul><li>An inflammatory disorder causing deep erosion of stomach or duodenal mucosa by HCL & pepsin  ...
Peptic Ulcer Disease <ul><li>Treatment includes:  </li></ul><ul><ul><li>< ETOH intake  </li></ul></ul><ul><ul><li>screen f...
Bowel   Disorders <ul><li>Ulcerative Colitis </li></ul><ul><ul><li>A disease that causes inflammation and sores in the lin...
Gastric Cancer <ul><li>Adenocarcinoma   is the primary malignant neoplasm  </li></ul><ul><ul><li>Etiology:chronic inflamma...
Colorectal Cancer <ul><li>“ Patients with long-standing ulcerative colitis have been shown to be at increased risk of deve...
Colorectal Cancer <ul><li>Symptoms:   </li></ul><ul><ul><li>fecal occult blood or ulcerative lesions manifest as anemia or...
Gastrointestinal Bleeding
Terms of GI Bleeding <ul><li>Hematemesis   – vomiting of blood (or coffee ground material) (indicates bleeding proximal to...
Localization of GI Bleeding <ul><li>Hematemesis  – always UGI source </li></ul><ul><li>Melana   – indicates that blood has...
GI Bleeding <ul><li>Upper:  includes the esophagus, stomach, duodenum   </li></ul><ul><ul><ul><li>peptic ulcer disease (PU...
Acute UGI Bleeding  Mallory-Weiss Tear <ul><li>Mucosal laceration at the GEJ </li></ul><ul><li>10% of cases </li></ul><ul>...
Acute UGI Bleeding Portal Hypertension <ul><li>Sources of bleeding: </li></ul><ul><ul><li>Esophageal varices </li></ul></u...
Acute UGI Bleeding Duodenal & Gastric Ulcer <ul><li>Most common etiology of UGI bleeding </li></ul><ul><li>Duodenum>stomac...
Acute UGI Bleeding Duodenal & Gastric Ulcer <ul><li>Predisposing factors for bleeding cont.: </li></ul><ul><ul><li>Gastric...
Duodenal & Gastric Ulcer
UGI Bleeding Gastric Erosions <ul><li>NSAID’s </li></ul><ul><li>Stress: </li></ul><ul><ul><li>Serious trauma </li></ul></u...
UGI Bleeding Malignancy <ul><li>Malignant: </li></ul><ul><ul><li>Esophageal cancer </li></ul></ul><ul><ul><li>Gastric canc...
UGI   Malignancy
Lower GI Bleeds <ul><li>Four most common causes of LGI bleeds </li></ul><ul><li>vascular ectasias </li></ul><ul><li>coloni...
LGI   bleeds   -   Other   Causes <ul><li>solitary rectal ulcer syndrome  (SRUS) </li></ul><ul><li>colonic varicies </li><...
Acute Lower GI Bleeding <ul><li>Initial management – similar to acute upper GI bleeding </li></ul><ul><li>Presentation: wi...
Acute Lower GI Bleeding Diverticulosis   of the Colon <ul><li>Common cause (25%) </li></ul><ul><li>Acute, painless, bright...
Acute Lower GI Bleeding Colonic AV Malformation <ul><li>Aka : Vascular Ectasias, Angiodysplasias, AV malformations </li></...
Acute Lower GI Bleeding Vascular Ectasias <ul><li>the right colon is subjected to numerous colonic distentions that cause ...
Vascular Ectasias - Treatment <ul><li>90 % stop spontaneously </li></ul><ul><li>80 % of the remainder stop after IV or int...
Acute Lower GI Bleeding Angiodysplasia  <ul><li>Presentation: </li></ul><ul><ul><li>Acute (recurrent) </li></ul></ul><ul><...
Acute Lower GI Bleeding   Angiodysplasia <ul><li>Diagnosis: </li></ul><ul><ul><li>Colonoscopy </li></ul></ul><ul><ul><li>A...
Angiodysplasia
Acute Lower GI Bleeding Hemorrhoids   <ul><li>Most common cause </li></ul><ul><li>Presentation: </li></ul><ul><ul><li>recu...
Lower GI Bleeding Mesenteric Vascular Occlusion <ul><li>Vascular insufficiency - occlusive vs. non </li></ul><ul><li>75 % ...
Acute Lower GI Bleeding Other Causes <ul><li>Meckel’s diverticulum </li></ul><ul><li>Infectious colitis: Shigella; Salmone...
Acute Lower GI Bleeding <ul><li>Evaluation of source: </li></ul><ul><li>History: </li></ul><ul><ul><li>Age (tumors & diver...
Acute Lower GI Bleeding <ul><li>Diagnostic procedures: </li></ul><ul><ul><li>Colonoscopy  </li></ul></ul><ul><ul><li>Tagge...
<ul><li>Effectiveness: </li></ul><ul><ul><li>Localization of bleeding site: : 57-72% </li></ul></ul><ul><ul><li>Reduced op...
Transcatheter Embolization  <ul><li>•  Initial control: 71 -100% </li></ul><ul><li>•  Rebleed rate : 0-12% </li></ul><ul><...
Occult bleeding <ul><li>Diagnosis: </li></ul><ul><ul><li>Imaging of the colon: </li></ul></ul><ul><ul><ul><li>Colonoscopy ...
GI Bleeding <ul><li>Do  Not  Underestimate GI Bleeding </li></ul><ul><ul><li>Don’t assume anything </li></ul></ul><ul><li>...
References <ul><li>Fundamentals of Diagnostic Radiology, 2nd edition (1999). Brant, William E. & Helms, Clyde A., eds. Wil...
References <ul><li>Givens BA, Simmons SJ: Gastroenterology in Clinical Nursing. 4th ed. St. Louis, Mo: C.V. Mosby Co, 1984...
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Gastrointestinal Disorders

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Gastrointestinal Disorders

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  • Gastrointestinal Disorders

    1. 1. Disorders of the Gastrointestinal System Orlando Regional Medical Center 2008
    2. 3. Intestinal Obstructions
    3. 4. Intestinal Obstruction <ul><li>Blockage of intestinal tract that inhibits passage of fluid, gas, feces </li></ul><ul><li>Caused by </li></ul><ul><ul><li>mechanical obstruction ( strangulated hernia, adhesion, cancer, volvulus, intussusception ) </li></ul></ul><ul><ul><li>neurogenic obstruction ( paralytic ileus, uremia, electrolyte imbalance(low K), spinal cord lesion ) </li></ul></ul><ul><ul><li>Vascular disease ( occlusion of superior mesentery vessels) </li></ul></ul>
    4. 5. Intestinal Obstructions <ul><li>Paralytic Ileus or “silent bowel” is most often seen after abdominal surgery & anesthesia </li></ul><ul><ul><ul><li>bowel activity is < due to lack of neural stimuli (“functional”) </li></ul></ul></ul><ul><ul><ul><li>this can lead to “mechanical” obstruction due to accumulation of feces </li></ul></ul></ul><ul><li>Hernias: a loop of bowel protrudes through abdominal wall </li></ul><ul><ul><ul><li>inguinal canal, umbilicus, or incisional scar tissue </li></ul></ul></ul><ul><ul><ul><li>caused by heavy lifting, straining, or coughing </li></ul></ul></ul>
    5. 6. Sigmoid Volvulus <ul><li>Sigmoid Volvulus (twisting): usually seen in the older individual with a history of straining at stool </li></ul><ul><ul><li>Symptoms: abdominal distention, nausea, vomiting, and crampy abdominal pain; check history of flatus and BMs </li></ul></ul><ul><ul><li>Abrupt onset is indicative of an acute obstruction </li></ul></ul><ul><ul><li>Sudden onset due to “torsion or hernia?” </li></ul></ul><ul><li>A chronic history of constipation is related to a dx of diverticulitis or carcinoma </li></ul><ul><li>Obstipation (no flatus or BM) & loss of weight = carcinoma </li></ul>
    6. 7. Sigmoid Volvulus
    7. 8. Intussusception <ul><li>only 5-15 % occurrence in adults </li></ul><ul><li>s/s colicky abd pain, nausea, vomit, diarrhea, constipation </li></ul><ul><li>diagnosed by barium enema, CT scan </li></ul><ul><li>treated via surgical resection </li></ul>
    8. 9. Intussusception
    9. 10. Small Bowel Obstruction <ul><li>“ Never let the sun rise or set on a small bowel obstruction.” </li></ul><ul><li>(surgical saying) </li></ul>
    10. 11. Small Bowel Obstruction <ul><li>Causes of SBO: </li></ul><ul><li>Adhesions (post-surgical, post-inflammatory) </li></ul><ul><li>Incarcerated hernia </li></ul><ul><li>Malignancy : usually metastatic </li></ul><ul><li>Intussusception </li></ul><ul><li>Volvulus </li></ul><ul><li>Gallstone ileus </li></ul><ul><li>Parasites </li></ul><ul><li>Foreign body </li></ul>
    11. 12. Small Bowel Obstruction <ul><li>Causes of small bowel obstruction include: </li></ul><ul><li>Adhesions from previous abdominal surgery </li></ul><ul><li>Hernias containing bowel </li></ul><ul><li>Crohn's disease causing adhesions or inflammatory strictures </li></ul><ul><li>Neoplasms benign or malignant </li></ul><ul><li>Intussusception in children </li></ul><ul><li>Volvulus </li></ul><ul><li>Superior mesenteric artery syndrome a compression of the duodenum by the superior mesenteric artery and the abdominal aorta </li></ul><ul><li>Ischemic strictures </li></ul><ul><li>Foreign bodies (e.g. gallstones in gallstone ileus, swallowed objects) </li></ul><ul><li>Intestinal atresia </li></ul><ul><li>Parasites </li></ul>
    12. 13. Small Bowel Obstruction <ul><li>Signs & Symptoms of Small Bowel Obstruction: </li></ul><ul><li>  Abdominal pain </li></ul><ul><li> Vomiting </li></ul><ul><li>   Elimination problems (Diarrhea) </li></ul><ul><li>   Bloating </li></ul>
    13. 14. Small Bowel Obstruction <ul><li>The essentials: </li></ul><ul><li>* Common, may or may not require surgery </li></ul><ul><li>* Emergent, if bowel is strangulated (to OR) </li></ul><ul><li>* KUB not necessarily diagnostic </li></ul><ul><li>-Shows dilated loops, air-fluid levels </li></ul><ul><li>* CT very sensitive and specific </li></ul><ul><li>-Better at transitional zone, cause of SBO </li></ul>
    14. 15. Small Bowel Obstruction
    15. 16. Large Bowel Obstruction <ul><li>A large bowel obstruction is an emergency condition that requires early & prompt surgical intervention </li></ul><ul><li>Etiology: </li></ul><ul><ul><ul><li>infectious / inflammatory, neoplastic, or mechanical pathology (colorectal cancer) </li></ul></ul></ul><ul><li>Rotation or twisting of the cecum or sigmoid colon will cause abrupt onset of symptoms </li></ul><ul><li>Immediate abdominal distention </li></ul><ul><ul><li>Decreases the ability to absorb Fluids & Electrolytes </li></ul></ul>
    16. 17. Large Bowel Obstruction <ul><li>Causes of large bowel obstruction include: </li></ul><ul><li>Neoplasms </li></ul><ul><li>Hernias </li></ul><ul><li>Inflammatory bowel disease </li></ul><ul><li>Colonic volvulus (sigmoid, caecal, transverse colon) </li></ul><ul><li>Fecal impaction </li></ul><ul><li>Colon atresia </li></ul><ul><li>Benign strictures (Diverticular Disease) </li></ul>
    17. 18. Large Bowel Obstruction <ul><li>Signs & Symptoms of Large Bowel Obstruction: </li></ul><ul><li>  Abdominal pain </li></ul><ul><li> Vomiting ( not common ) </li></ul><ul><li>   Elimination problems (Constipation or Loose) </li></ul><ul><li>   Bloating </li></ul>
    18. 19. Large Bowel Obstruction
    19. 20. When to Operate? <ul><li>Incarcerated or strangulated hernia </li></ul><ul><li>Peritonitis </li></ul><ul><li>Pneumoperitoneum </li></ul><ul><li>Suspected strangulation </li></ul><ul><li>Closed loop obstruction </li></ul><ul><li>Complete obstruction </li></ul><ul><li>Virgin abdomen </li></ul><ul><li>LARGE bowel obstruction </li></ul>
    20. 21. Gastrointestinal Disorders
    21. 22. Diarrhea <ul><li>Causes of Diarrhea </li></ul><ul><ul><li>Osmotic : the presence of nonabsorbable substances in the intestine causing water to be drawn into the lumen by osmosis </li></ul></ul><ul><ul><ul><li>sorbitol-containing liquid medications; tube feedings </li></ul></ul></ul><ul><ul><ul><li>lactose intolerance </li></ul></ul></ul><ul><ul><li>Secretory : excessive mucosal secretion of fluid & electrolytes </li></ul></ul><ul><ul><ul><li>related to: gastroenteritis (E. Coli), rotavirus, laxative abuse, hyponatremia, fecal impaction </li></ul></ul></ul>
    22. 23. Intestinal Ulcers
    23. 24. Peptic Ulcer Disease <ul><li>An inflammatory disorder causing deep erosion of stomach or duodenal mucosa by HCL & pepsin </li></ul><ul><li>At risk: infection with H. pylori; > NSAIDS; > secretion of HCL as seen in Zollinger-Ellison syndrome </li></ul><ul><li>Etiology: age, family hx </li></ul><ul><ul><li>> mucolytic enzymes; may lead to pyloric obstruction, bowel perforation and ultimately peritonitis </li></ul></ul><ul><li>Sx: hallmark sign = upper gastric pain </li></ul><ul><ul><li>Emergency: hematemesis, melena, occult blood, shock </li></ul></ul>
    24. 25. Peptic Ulcer Disease <ul><li>Treatment includes: </li></ul><ul><ul><li>< ETOH intake </li></ul></ul><ul><ul><li>screen for H. pylori (C-urea breath test) </li></ul></ul><ul><ul><li>frequent small meals </li></ul></ul><ul><ul><li>avoid calcium based antacids d/t > gastrin release </li></ul></ul><ul><ul><li>H2 blockers (Tagamet & Zantac) </li></ul></ul><ul><ul><li>Insert NG tube for severe bleeding and gastric lavage </li></ul></ul>
    25. 26. Bowel Disorders <ul><li>Ulcerative Colitis </li></ul><ul><ul><li>A disease that causes inflammation and sores in the lining of the large intestine. </li></ul></ul><ul><li>Crohn’s Disease </li></ul><ul><ul><li>A disease that causes inflammation in the small intestine, but it may affect any part of the GI tract. </li></ul></ul><ul><ul><li>Smoking, diet, and/or immune response to bacteria </li></ul></ul>
    26. 27. Gastric Cancer <ul><li>Adenocarcinoma is the primary malignant neoplasm </li></ul><ul><ul><li>Etiology:chronic inflammation, dietary influences, genetic & environmental factors </li></ul></ul><ul><ul><ul><li>8th leading cause of mortality r/t cancer in US </li></ul></ul></ul><ul><ul><ul><li>Epidemiology: 55-60 year olds; 2 times greater incidence in men vs. women </li></ul></ul></ul><ul><ul><ul><li>Risk factors: H. pylori, < socioeconomic class, consumption of pickled foods, improper food storage, radiation exposure </li></ul></ul></ul>
    27. 28. Colorectal Cancer <ul><li>“ Patients with long-standing ulcerative colitis have been shown to be at increased risk of developing colorectal cancer” (Medscape, 1999) </li></ul><ul><li>Involves a primary malignant tumor of the rectum or colon </li></ul><ul><ul><ul><li>2nd leading cause of cancer death in US </li></ul></ul></ul><ul><ul><ul><li>> incidence in 50 year olds </li></ul></ul></ul><ul><ul><ul><li>> fat and poor fiber diet; > ETOH consumption; cigarette smoking; obesity; sedentary life style </li></ul></ul></ul><ul><li>Exact etiology unknown…> incidence with polyps </li></ul>
    28. 29. Colorectal Cancer <ul><li>Symptoms: </li></ul><ul><ul><li>fecal occult blood or ulcerative lesions manifest as anemia or rectal bleeding </li></ul></ul><ul><ul><ul><li>distention, abdominal pain, vomiting, constipation </li></ul></ul></ul><ul><ul><li>metastatic disease: weight loss, anorexia, possible palpable mass </li></ul></ul><ul><li>Prevention: ASA may < risk; routine monitoring for guaic (+) </li></ul><ul><li>Treatment: colostomy repair; permanent colostomy for rectal tumors </li></ul>
    29. 30. Gastrointestinal Bleeding
    30. 31. Terms of GI Bleeding <ul><li>Hematemesis – vomiting of blood (or coffee ground material) (indicates bleeding proximal to the Treitz) </li></ul><ul><li>Melena – passage of black tarry stools > 50ml (indicates degradation of blood in the bowel) </li></ul><ul><li>Hematochezia (rectal bleeding) – passage of red blood </li></ul><ul><li>Occult Bleeding – bleeding that is not apparent to the patient and results from small amounts of blood </li></ul><ul><li>Obscure Bleeding – occult or obvious but source not identified </li></ul>
    31. 32. Localization of GI Bleeding <ul><li>Hematemesis – always UGI source </li></ul><ul><li>Melana – indicates that blood has been in GIT for extended periods </li></ul><ul><ul><li>Mostly UGI </li></ul></ul><ul><ul><li>Small bowel </li></ul></ul><ul><ul><li>Right colon (if bleeding relatively slow) </li></ul></ul><ul><li>Hematochezia </li></ul><ul><ul><li>Mostly colon </li></ul></ul><ul><ul><li>Massive UGI bleeding (not enough time for degradation) </li></ul></ul>
    32. 33. GI Bleeding <ul><li>Upper: includes the esophagus, stomach, duodenum </li></ul><ul><ul><ul><li>peptic ulcer disease (PUD) or esophageal varices </li></ul></ul></ul><ul><li>Lower: includes the jejunum, ileum, colon, rectum </li></ul><ul><ul><ul><li>colorectal cancer, polyps, hemorrhoids, IBD </li></ul></ul></ul><ul><li>Manifestations: </li></ul><ul><ul><ul><li>hematemesis </li></ul></ul></ul><ul><ul><ul><li>bright red blood in the stool (“ hematochezia ”) </li></ul></ul></ul><ul><ul><ul><li>black,dark, tarry stools (“ melena ”) </li></ul></ul></ul><ul><ul><ul><li>“ occult ” bleeding (invisible blood in the stool) </li></ul></ul></ul><ul><li>Treatment: find the underlying cause; fluid volume replacement; endoscopy or colonoscopy; medical and /or surgical therapy </li></ul>
    33. 34. Acute UGI Bleeding Mallory-Weiss Tear <ul><li>Mucosal laceration at the GEJ </li></ul><ul><li>10% of cases </li></ul><ul><li>Typically follows retching but mostly on 1st vomit (75%) </li></ul><ul><li>90% stop bleeding spontaneously </li></ul><ul><li>Endoscopic Therapy sometimes required </li></ul>
    34. 35. Acute UGI Bleeding Portal Hypertension <ul><li>Sources of bleeding: </li></ul><ul><ul><li>Esophageal varices </li></ul></ul><ul><ul><li>Gastric varices </li></ul></ul><ul><ul><li>Portal hypertensive gastropathy </li></ul></ul><ul><li>Urgent gastroscopy: </li></ul><ul><ul><li>Sclerotherpay </li></ul></ul><ul><ul><li>Band ligation </li></ul></ul><ul><li>Somatostatin </li></ul><ul><li>Balloon tamponade (Sengstaken-Blackmore tube) </li></ul>
    35. 36. Acute UGI Bleeding Duodenal & Gastric Ulcer <ul><li>Most common etiology of UGI bleeding </li></ul><ul><li>Duodenum>stomach </li></ul><ul><li>Predisposing factors for bleeding: </li></ul><ul><ul><li>NSAID’s </li></ul></ul><ul><ul><li>Underlying medical conditions: IHD; cerebrovascular disease </li></ul></ul><ul><ul><li>Ethanol, anticoagulant Therapy </li></ul></ul><ul><ul><li>Hospitalization </li></ul></ul>
    36. 37. Acute UGI Bleeding Duodenal & Gastric Ulcer <ul><li>Predisposing factors for bleeding cont.: </li></ul><ul><ul><li>Gastric acid </li></ul></ul><ul><ul><li>H. Pylori: Role in bleeding not certain but definitely, eradication prevents rebleeding </li></ul></ul><ul><ul><li>Aspirin & NSAID’s: </li></ul></ul>
    37. 38. Duodenal & Gastric Ulcer
    38. 39. UGI Bleeding Gastric Erosions <ul><li>NSAID’s </li></ul><ul><li>Stress: </li></ul><ul><ul><li>Serious trauma </li></ul></ul><ul><ul><li>Extensive burns </li></ul></ul><ul><ul><li>Major surgery </li></ul></ul><ul><ul><li>Major illness (ICU) </li></ul></ul><ul><ul><li>Major neurological disease (CVA, tumor, trauma) </li></ul></ul><ul><li>Alcohol abuse </li></ul>
    39. 40. UGI Bleeding Malignancy <ul><li>Malignant: </li></ul><ul><ul><li>Esophageal cancer </li></ul></ul><ul><ul><li>Gastric cancer or lymphoma </li></ul></ul><ul><ul><li>Small intestinal lymphoma or cancer </li></ul></ul><ul><li>Benign: </li></ul><ul><ul><li>Leiomyoma </li></ul></ul>
    40. 41. UGI Malignancy
    41. 42. Lower GI Bleeds <ul><li>Four most common causes of LGI bleeds </li></ul><ul><li>vascular ectasias </li></ul><ul><li>colonic diverticuli </li></ul><ul><li>neoplasm </li></ul><ul><li>internal hemorrhoids </li></ul>
    42. 43. LGI bleeds - Other Causes <ul><li>solitary rectal ulcer syndrome (SRUS) </li></ul><ul><li>colonic varicies </li></ul><ul><li>mesenteric vascular insufficiency </li></ul><ul><li>ischemic colitis </li></ul><ul><li>Meckel’s diverticulum </li></ul><ul><li>small intestinal ulceration </li></ul><ul><li>intussusception </li></ul><ul><li>radiation-induced injury </li></ul><ul><li>diversion colitis </li></ul><ul><li>mesenteric venous thrombosis </li></ul><ul><li>small bowel diverticuli </li></ul><ul><li>Dieulafoy lesion </li></ul><ul><li>vasculitis </li></ul><ul><li>long-distance running </li></ul><ul><li>endometriosis </li></ul>
    43. 44. Acute Lower GI Bleeding <ul><li>Initial management – similar to acute upper GI bleeding </li></ul><ul><li>Presentation: wide range of presentation: </li></ul><ul><ul><li>Mostly self-limiting bleeding that does not require hospitalization </li></ul></ul><ul><ul><li>Rarely massive with hemorrhagic shock </li></ul></ul>
    44. 45. Acute Lower GI Bleeding Diverticulosis of the Colon <ul><li>Common cause (25%) </li></ul><ul><li>Acute, painless, bright red, maroon or melena (depending on site) </li></ul><ul><li>May compromise hemodynamics (elderly) </li></ul><ul><li>Diagnosis: per exclusion </li></ul><ul><li>Significant recurrence </li></ul><ul><li>Treatment: most subside spontaneously, some need angiographic embolization or surgery </li></ul>
    45. 46. Acute Lower GI Bleeding Colonic AV Malformation <ul><li>Aka : Vascular Ectasias, Angiodysplasias, AV malformations </li></ul><ul><li>They are : </li></ul><ul><ul><li>degenerative lesions of previously normal blood vessels located in the cecum and ascending colon </li></ul></ul><ul><li>They are not : </li></ul><ul><ul><li>telangiectasias, congenital defect, hemangiomas </li></ul></ul>
    46. 47. Acute Lower GI Bleeding Vascular Ectasias <ul><li>the right colon is subjected to numerous colonic distentions that cause intermittent obstruction of the submucousal veins outflow tract leading to their dilation </li></ul>
    47. 48. Vascular Ectasias - Treatment <ul><li>90 % stop spontaneously </li></ul><ul><li>80 % of the remainder stop after IV or intra-arterial vasopressin </li></ul><ul><li>transcatheter embolization </li></ul><ul><li>laser </li></ul><ul><li>endoscopic sclerosis </li></ul><ul><li>heater probe </li></ul><ul><li>electrocoagulate </li></ul><ul><li>surgery </li></ul>
    48. 49. Acute Lower GI Bleeding Angiodysplasia <ul><li>Presentation: </li></ul><ul><ul><li>Acute (recurrent) </li></ul></ul><ul><ul><li>Chronic </li></ul></ul><ul><ul><li>Occult </li></ul></ul><ul><li>Older pts (mainly>70) </li></ul><ul><li>High association with CRF </li></ul><ul><li>Most – right colon </li></ul>
    49. 50. Acute Lower GI Bleeding Angiodysplasia <ul><li>Diagnosis: </li></ul><ul><ul><li>Colonoscopy </li></ul></ul><ul><ul><li>Angiography </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Electrocoagulation </li></ul></ul><ul><ul><li>Injection </li></ul></ul><ul><ul><li>LASER </li></ul></ul><ul><ul><li>Surgery </li></ul></ul>
    50. 51. Angiodysplasia
    51. 52. Acute Lower GI Bleeding Hemorrhoids <ul><li>Most common cause </li></ul><ul><li>Presentation: </li></ul><ul><ul><li>recurrent low-volume bright red blood on the paper or on stool </li></ul></ul><ul><ul><li>Straining aggravates bleeding </li></ul></ul><ul><ul><li>Rarely associated with anemia (acute or chronic) </li></ul></ul><ul><li>Never relate bleeding to hemorrhoids before exclusion of other lesions </li></ul>
    52. 53. Lower GI Bleeding Mesenteric Vascular Occlusion <ul><li>Vascular insufficiency - occlusive vs. non </li></ul><ul><li>75 % from mesenteric a. emboli </li></ul><ul><li>usu. elderly presenting as acute abd pain, concomitant heart disease, spontaneous GI bleed, pain out-of-proportion with the PE </li></ul><ul><li>mortality 50 - 90 % </li></ul><ul><li>diagnosed by arteriography </li></ul><ul><li>treated by emergent ex lap </li></ul>
    53. 54. Acute Lower GI Bleeding Other Causes <ul><li>Meckel’s diverticulum </li></ul><ul><li>Infectious colitis: Shigella; Salmonella; campylobacter </li></ul><ul><li>Radiation proctitis </li></ul><ul><li>Ischemic colitis </li></ul><ul><li>IBD – colitis (UC;CD) </li></ul>
    54. 55. Acute Lower GI Bleeding <ul><li>Evaluation of source: </li></ul><ul><li>History: </li></ul><ul><ul><li>Age (tumors & diverticular disease more common in elderly pts; IBD more common in young) </li></ul></ul><ul><ul><li>HIV (CMV colitis) </li></ul></ul><ul><ul><li>NSAID’s </li></ul></ul><ul><ul><li>Family or personal Hx of polyps or CRC </li></ul></ul><ul><ul><li>Change in bowel habits </li></ul></ul><ul><ul><li>Pain (in IBD, ischemic colitis…); Anal pain </li></ul></ul><ul><ul><li>Previous abdominal irradiation </li></ul></ul><ul><ul><li>Previous surgery (particularly vascular) </li></ul></ul><ul><ul><li>ASCVD (ischemic colitis) </li></ul></ul>
    55. 56. Acute Lower GI Bleeding <ul><li>Diagnostic procedures: </li></ul><ul><ul><li>Colonoscopy </li></ul></ul><ul><ul><li>Tagged RBC Scintigraphy – low predictive value </li></ul></ul><ul><ul><li>Angiography + Embolization </li></ul></ul><ul><ul><li>Surgery (rare) </li></ul></ul>
    56. 57. <ul><li>Effectiveness: </li></ul><ul><ul><li>Localization of bleeding site: : 57-72% </li></ul></ul><ul><ul><li>Reduced operative mortality: : 9-14% vs.. 37-50% </li></ul></ul>Angiography
    57. 58. Transcatheter Embolization <ul><li>• Initial control: 71 -100% </li></ul><ul><li>• Rebleed rate : 0-12% </li></ul><ul><li>• Ischemia: 0-21% </li></ul>
    58. 59. Occult bleeding <ul><li>Diagnosis: </li></ul><ul><ul><li>Imaging of the colon: </li></ul></ul><ul><ul><ul><li>Colonoscopy </li></ul></ul></ul><ul><ul><ul><li>DC barium enema </li></ul></ul></ul><ul><ul><ul><li>CTC </li></ul></ul></ul><ul><ul><li>Gastroscopy </li></ul></ul><ul><ul><li>Small bowel follow-through </li></ul></ul><ul><ul><li>Video-capsule </li></ul></ul>
    59. 60. GI Bleeding <ul><li>Do Not Underestimate GI Bleeding </li></ul><ul><ul><li>Don’t assume anything </li></ul></ul><ul><li>Do Not Ignore Bright Red Bleeding </li></ul><ul><ul><li>Monitor VS </li></ul></ul><ul><ul><li>Don’t assume anything </li></ul></ul><ul><li>Do Not Overreact to GI Bleeding </li></ul><ul><ul><li>Monitor VS </li></ul></ul><ul><li>Do Report GI Bleeding </li></ul><ul><ul><li>Don’t assume anything </li></ul></ul>
    60. 61. References <ul><li>Fundamentals of Diagnostic Radiology, 2nd edition (1999). Brant, William E. & Helms, Clyde A., eds. Williams and Wilkins, Baltimore MD. </li></ul><ul><li>Delabrousse, E., Destrumelle N., Brunelle S., Clair C., Mantion G., Kastler B. (2003) CT of small bowel obstruction in adults. Abdominal Imaging 28(2): 257-266. </li></ul><ul><li>www.uptodate.com: Clinical manifestations and diagnosis of small bowel obstruction; Treatment of small bowel obstruction; Abdominal wall and groin hernias. </li></ul><ul><li>Hansen, M. (1998). Pathophysiology: Foundations of disease and clinical intervention. Philadelphia: Saunders. </li></ul><ul><li>http://www.medscape.com </li></ul><ul><li>Givens BA, Simmons SJ: Gastroenterology in Clinical Nursing. 4th ed. St. Louis, Mo: C.V. Mosby Co, 1984.  </li></ul><ul><li>Ripamonti C, Bruera E: Palliative management of malignant bowel obstruction. Int J Gynecol Cancer 12 (2): 135-43, 2002 Mar-Apr.  [PUBMED Abstract] </li></ul><ul><li>Potluri V, Zhukovsky DS: Recent advances in malignant bowel obstruction: an interface of old and new. Curr Pain Headache Rep 7 (4): 270-8, 2003.  [PUBMED Abstract] </li></ul><ul><li>Baron TH: Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med 344 (22): 1681-7, 2001. PUBMED Abstract] </li></ul><ul><li>Mercadante S: Assessment and management of mechanical bowel obstruction. In: Portenoy RK, Bruera E, eds.: Topics in Palliative Care. Volume 1. New York, NY: Oxford University Press, 1997, pp. 113-30.  </li></ul>
    61. 62. References <ul><li>Givens BA, Simmons SJ: Gastroenterology in Clinical Nursing. 4th ed. St. Louis, Mo: C.V. Mosby Co, 1984.  </li></ul><ul><li>Ripamonti C, Bruera E: Palliative management of malignant bowel obstruction. Int J Gynecol Cancer 12 (2): 135-43, 2002 Mar-Apr.  [PUBMED Abstract] </li></ul><ul><li>Potluri V, Zhukovsky DS: Recent advances in malignant bowel obstruction: an interface of old and new. Curr Pain Headache Rep 7 (4): 270-8, 2003.  [PUBMED Abstract] </li></ul><ul><li>Baron TH: Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med 344 (22): 1681-7, 2001.  PUBMED Abstract] Mercadante S: Assessment and management of mechanical bowel obstruction. In: Portenoy RK, Bruera E, eds.: Topics in Palliative Care. Volume 1. New York, NY: Oxford University Press, 1997, pp. 113-30.  </li></ul>
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