Adapt procedures to amount of bleeding
Adapt procedures to amount of bleeding
Guidelines from the American Society for Gastrointestinal Endoscopy in Manchester, MA, include the following major recommendations for patients with acute lower gastrointestinal (GI) bleeding:1
Moderate bleeding.
1. For moderate bleeding per rectum not sufficient to require immediate transfusion, upper or lower GI barium contrast studies aren’t recommended early in the evaluation because they will interfere with subsequent endoscopic or angiographic studies.
2. Examine the anus and rectum by either a rigid or flexible endoscope. If the anorectum isn’t the source of bleeding, perform colonoscopy next. A bleeding site will be more easily identified if the patient is first rapidly prepared with oral lavage.
3. If bleeding has stopped and the patient doesn’t require emergency surgery, or if an unprepared examination hasn’t been done, then a complete colonoscopic examination of a well-prepared colon should be done.
4. If complete colonoscopy if negative, and if bleeding doesn’t recur within a few days, barium X-rays may be considered. The alternatives are to monitor the patient carefully or obtain other imaging studies.
Massive bleeding.
1. For massive bleeding with acute loss of large volumes of blood per rectum from a source in the upper or lower GI tract, the first priority is to stabilize the patient with fluids and transfusions if necessary. Begin diagnostic work-up of patients while those resuscitative efforts are under way, or as soon as the patient is stable, depending on the severity of the situation.
2. Insert a nasogastric tube and observe gastric aspirate for visible blood. If there is suspicion of an upper GI bleeding source, upper endoscopy should be performed even if the stomach contains no blood. Barium contrast studies aren’t indicated at this time.
3. Investigate the distal large bowel with anoscopy and sigmoidoscopy. Preparation with enemas may not be practical depending on the amount of bleeding.
4. If no bleeding site is seen in the rectum or rectosigmoid, the entire colon should be examined. The two strategies that can be used are angiography with or without preceding radionuclide scan or colonoscopy. Both procedures have advantages and disadvantages. For example, angiography allows for localization of rapid bleeding, but it carries a risk of contrast media allergic reactions or nephrotoxicity. Emergency colonoscopy discloses a bleeding lesion in the colon in 50% to 70% of patients, but there is an increased risk of perforation and a delay of one to three hours to prepare the colon.
The use of one modality over another is not recommended until comparative long-term morbidity and mortality data from use of angiography or colonoscopy become available.
Reference
1. American Society for Gastrointestinal Endoscopy Standards of Training and Practice Committee. The role of endoscopy in the patient with lower gastrointestinal bleeding: Guidelines for clinical application. Manchester, MA; 1996.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.