2/3/2010




                       Abdullah Al-Abdali
                            R2 EM




             Outline

Case di...
2/3/2010




82 years old female, presented with:
  Bloody diarrhea with fresh blood
  Abdominal pain
  hematurea




    ...
2/3/2010




  Sick looking
     P: 110
     BP:85/55
     T:36.9
     sat: 96% on RA
     CRT ??




 0
1 survey
A: paten...
2/3/2010




        Intervention ??




NS boluses
Blood ordered, 6U

Post resuscitation
  P:92
  BP:100/60
  Sat:100% on...
2/3/2010




                History

              2nd survey


                  DDx


             Consultation


     ...
2/3/2010




              History

HTN = not on medication currently
Dx 5 months back as leaking
descending Aortic aneury...
2/3/2010




               Consultations

 General surgery
 Cardio-thoracic surgery
 Cardiology
 Acute medical admission
...
2/3/2010




          General surgery

For urgent CT angio.
To be seen by cardio-thoracic




   Cardio-thoracic surgery
...
2/3/2010




             Cardiology

 Bed side ECHO done:
 Normal LV size
 EF:40%
 Normal LA size grade 2 MR
 Mild AS
 Di...
2/3/2010




                      CT report

Impression:
   Thoracic aneurysm
   Possibility of subintimal intramural ble...
2/3/2010




                 OT
There was blood inside the last 20-30
cm of ileum, there were multiple
ulcers seen with b...
2/3/2010




                         Etiology
Common causes of lower gastrointestinal bleeding
  Anatomical
       Divert...
2/3/2010




                    Clinical approach
    Patients should be categorized as:
        low risk
        high ri...
2/3/2010




General surgery and gastroenterology
should be involved earlier in
management.

Investigations
  In patients ...
2/3/2010




        Take home message:
Visible rectal bleeding occurring in adults warrants an evaluation in
all cases. P...
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Transcript of "Case Presentation"

  1. 1. 2/3/2010 Abdullah Al-Abdali R2 EM Outline Case discussion Clinical approach to such cases 1
  2. 2. 2/3/2010 82 years old female, presented with: Bloody diarrhea with fresh blood Abdominal pain hematurea primary survey vital signs 2
  3. 3. 2/3/2010 Sick looking P: 110 BP:85/55 T:36.9 sat: 96% on RA CRT ?? 0 1 survey A: patent B: normal, RR 14, sPO2 96% in RA, C: P 110, BP 85/55, T 36.9 D: GCS; (14/15), pupils reacting b/l, RBS 7.2 E: NAD 3
  4. 4. 2/3/2010 Intervention ?? NS boluses Blood ordered, 6U Post resuscitation P:92 BP:100/60 Sat:100% on 100% O2 4
  5. 5. 2/3/2010 History 2nd survey DDx Consultation Investigation 2nd survey H&N ….. Normal Chest ….. Reduce air entry in lower base B/L CVS …… S1+S2, ESM Abdomen: slightly distended, Soft, tender all over PR: fresh blood in the glove, no mass felt CNS :no obvious neurologic deficit. ECG: sinus tachycardia 5
  6. 6. 2/3/2010 History HTN = not on medication currently Dx 5 months back as leaking descending Aortic aneurysm not fit for any surgical intervention. B/L pleural effusion under Ix, but she sign LAMA. DDx aortoenteric fistula Aortic Aneurysm leakage Diverticulosis, Angiodysplasia Cancer 6
  7. 7. 2/3/2010 Consultations General surgery Cardio-thoracic surgery Cardiology Acute medical admission Gastroenterology CBC: U/E: HB: 5 Na:140 Hct: 16% K: 4 Plt: 80.4 Urea: 13.7 WBC: 62 creat:115 ANC:47.1 coagulation: LFT: PT:13.8 Normal APTT:34.2 CT angio 7
  8. 8. 2/3/2010 General surgery For urgent CT angio. To be seen by cardio-thoracic Cardio-thoracic surgery To stabilize the patient and to Do CT angio (chest & abdomen) To consult cardiologist for assessment CT angio= Thoracic Aortic aneurism not increased in size and no leakage from it. SO, no cardiothoracic interference required at present, and to be seen by general medicine for further Management 8
  9. 9. 2/3/2010 Cardiology Bed side ECHO done: Normal LV size EF:40% Normal LA size grade 2 MR Mild AS Dilated Descending AO She is high risk for surgery and GA Acute medical admission d/w Gastro on call, advised admission under acute medicine as pt need stabilization To start Omeprazol and octriotide To f/u official CT report 9
  10. 10. 2/3/2010 CT report Impression: Thoracic aneurysm Possibility of subintimal intramural bleed Active intraluminal bleed in short segment of distal small bowel loop seen at left lower abdomen. B/L pleural effusion, more in L. side Back to surgery Surgically patient is high risk & needs optimal localization via selective mesenteric angio with possible emboilization. OGD done Colonoscopy done Selective angio done= no abnormal vascularity seen, tiny bleeding into the lumen of small bowel at they Lt, para-lumbar area. 10
  11. 11. 2/3/2010 OT There was blood inside the last 20-30 cm of ileum, there were multiple ulcers seen with bleeding, Resection done of about 20-30cm of ileum down to about 10cm from ileo-caecal valve. Clinical approach to lower GI bleeding (LGIB) refers to blood loss of recent onset originating from a site distal to the ligament of Treitz. 11
  12. 12. 2/3/2010 Etiology Common causes of lower gastrointestinal bleeding Anatomical Diverticulosis, Vascular Angiodysplasia Ischemic Radiation-induced telangiectasia Inflammatory Infectious Idiopathic inflammatory bowel disease Neoplastic Polyp Carcinoma Others Hemorrhoid Ulcer Post biopsy or polypectomy Diverticulosis — 33 % Cancers/polyps — 19 % Colitis/ulcers (including inflammatory bowel disease, infectious, ischemic, and radiation colitis, vasculitis, and inflammation of unknown cause) — 18 % Unknown — 16 % Angiodysplasia — 8 % Miscellaneous (postpolypectomy, aortocolonic fistula, stercoral ulcer, anastomotic bleeding) — 8 % Anorectal (hemorrhoids, fissures, and idiopathic rectal ulcers) — 4 % 12
  13. 13. 2/3/2010 Clinical approach Patients should be categorized as: low risk high risk Low risk: High risk*: (eg, a young otherwise including those with: healthy patient with -hemodynamic instability, self-limited rectal -serious comorbid diseases, bleeding that is most -persistent bleeding, likely due to an -the need for multiple blood internal haemorrhoid) transfusions may be evaluated in -evidence of an acute Abdomen the outpatient setting. Resuscitation All patients with: hemodynamic instability (shock, orthostatic hypotension), evidence of severe bleeding (eg, a decrease in hematocrit of at least 6 %, or transfusion requirement greater than two units of packed red blood cells) continuous active bleeding should be admitted to an intensive care unit for resuscitation and close observation 13
  14. 14. 2/3/2010 General surgery and gastroenterology should be involved earlier in management. Investigations In patients with bleeding suspected to be coming from a lower GI source, colonoscopy is suggested (grade 2B). 14
  15. 15. 2/3/2010 Take home message: Visible rectal bleeding occurring in adults warrants an evaluation in all cases. Patients should be categorized as either low or high risk for complications based upon their clinical presentation and hemodynamic status. Patients with hemodynamic instability, with evidence of severe bleeding or continuous active bleeding should be admitted to an intensive care unit for resuscitation and close observation. follow guidelines that have been issued by the American College of Gastroenterology and approved by the American gastroenterological Association and the American Society for Gastrointestinal Endoscopy for evaluation of the patient with presumed lower gastrointestinal bleeding. THANK YOU 15

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