Hematochezia
At the end of this module, the student should be
able to:
1.
Diagnose the cause and distinguish a lower GI bleed from an upper GI
bleed
2. Outline the physiologic response to acute
massive lower GI bleed
3. Propose medical or
surgical management plan for lower GI bleed
4.
Advise patient for diagnostic and management options to GI
bleed
5. Describe and perform appropriate procedure
like NGT insertion and rectal examination
I. WORKING PROBLEM
STRAND
To achieve
the terminal objectives, the students should
know the:
A. Biological
Perspective
Anatomy
Anatomy of the Lower GI from the ligament of Treitz to anus ( Gross and
Microscopic)
Trace vascular Supply of the lower
GI
Physiology
Outline of the physiologic response to massive GI
bleeding
Time required for fluid shift in response to GI
bleed
Role and limitation for measurement of hemoglobin and Hematocrit in acute GI
bleeding
Physiologic estimation of blood
loss
Immunologic basis for blood
typing
Biochemistry
Guaiac stool test for occult blood - biochemical
basis
Pathology
List the important cause of GI bleeding and their respective mechanism for
bleeding
Diverticulosis
Angiodysplasia
Colonic
Ca
Ulcerative
colitis
Inflammatory bowels
syndrome
Infectious colitis - amoebic
colitis
Meckel's
Diverticulum
Intussuception
Hemorrhoids
Anal
Fissure
Microbiology
Pitfalls in the microsocpic diagnosis of
amoebiasis
Pharmacology
Anti-amoebic drugs - pharmacokinetics and
indications
Use of fresh frozen
plasma
Antibiotics role in
diverticulitis
Vasopresin
Medicine
Outline the emergency management of patient with
massive
GI
bleed
Understand how the patient is prepared for and monitored during blood
transfusion
State the indication for transfusion of
uncross-matched
blood and blood type utilized if the
patients
blood type is
unknown
Tilt Test- significance , indication and
contraindication
Diagnostic approach to diagnosis of LGI
bleed
Colonoscopy
Barium Enema - double air
contrast
Arteriography -
angiography
Tc-SC
scan
Proctosigmoidoscopy
Treatment options and the choice of haemostatic
modality
Endoscopic
diathermy
laser
coagulation
injection
sclerotherapy
Embolisation
Surgical treatment criteria ( indication for
surgery)
High fiber diet
role
B. Behavioral
Perspective
Medico-ethical issues on
emergency blood
transfusion
Understanding the feelings of patient as regards to diagnostic
procedure ( their fear and anxiety
)
II. PROFESSIONAL SKILL
STRAND
Indications for NGT
insertion
Indication for rectal
examination
Procedural steps for NGT
insertion
Choice of appropriate size of
NGT
III. COMMUNITY
STRAND
Population at risk for Lower GI
bleeding
Community Health plan for the control of amoebic colitis in the
community
Trigger 1
Mrs. Tomasa Calabasa ., 69 y.o., female, retired nurse from Lustre, Z.C.,
consulted because of hematoschezia.
|
1. What is her problem?
2. What is hematochezia?
List your
hypothesis as to the cause and suggest a mechanism by which the hypothesis can
lead to the presenting problem.
3. What additional information do you need
from Mrs. C.? |
Questions for the tutor:
Sample questions for tutors to use as
prompts:
1. What questions do you want to ask Mrs. C. regarding her
problem? Why are you asking these questions?
2. What are the anatomical
structures involved in bleeding in the intestinal tract?
3. What is the
significance of the color of the
blood?
What is the difference between melena and tarry
stools?
Maroon colored stools?
4. What does the rate of bleeding have to do with the
color of the stools or is it the length of the bowel in relation to transit
time? How about transit time?
5. Discuss the possible causes - mechanism of
bleeding in the following
entities:
Infection/inflammation - shigellosis, amoebiasis,
colitis
Parasitic infestations -
pinworms
Anal and rectal lesions - hemorrhoids,
fissures
Colonic
lesions - angiodysplasia, polyps,
cancer
Diverticula
PUD
Esophageal
varices
Stress
Ulcers
Gastritis
Esophagitis
Learning Goals:
1.
Different diseases causing bleeding from the lower
GI.
2. Clinical differentiation between
UGIB and LGIB
3. Clinical
Manifestations
4. Etiopathogenesis of
GIB
Trigger 2
Her condition was noted a
few hours prior to admission when the patient complained of hematochezia of
three episodes amounting to a cupful per episode. There was no alteration in
urination. There was no cough, chest pain nor fever.
The patient was
admitted to a private hospital about a year ago because of lower GI bleeding and
several times at another hospital because of essential
hypertension.
There is a history of diabetes in the family. The patient
denies smoking nor drinking alcoholic beverages.
There was no recent
intake of any medications.
|
Tutors Prompt:
1. Lead the students to reformulate
their earlier hypothesis based on the new information.
2. Why did you
reformulate your hypothesis that way?
3. What other information would you
require at this time? |
Potential Learning issues to
cover
1.
Significance of the amount of bleeding? Frequency of
bleeding
2. Effect of
bleeding on the patient..
hemodynamically..
3.
What is the significance of the history of bleeding episode
before?
4. Is the
hypertension a risk
factor?
5. Systemic
versus local cause of bleeding?
Prompts to help students inter-connect
learning issues from other modules with this case.
1. Risk factor for
bleeding from the gastrointestinal tract.
2. Hypertension and vascular
accidents (SMA thrombosis... intestinal angina..
ischemia)
Trigger 3
The physical examination of
the
patient:
Elderly female, undernourished, conscious, coherent, ambulatory
not
in distress with the following vital
signs:
BP =
180/100
HR =
80/min
RR =
22/min
Head and Neck : pinkish palpebral
conjunctiva
anicteric
sclera
supple
neck
Chest : clear breath sounds: (-)
crackles
Heart : regular rate and rhythm; no
murmurs
Abdomen flat, soft, (-)
organomegaly
Rectal Exam : good tone; (-) tenderness, (+) blood on the
examining
finger: no
external
hemorrhoids; no masses
|
Tutor Prompts
1. Ask students to review and re-rank
hypothesis in the light of new information from the P.E.
2. Discuss
ano-rectal lesions which can be seen and palpated.
3. Discuss how they would
like to work this patient up if they were the attending physician.
4. Change
scenario to a massive bleeding episode with hypotension, tachycardia ..
pallor |
Learning Goals
Review the resuscitative measures for a
patient with lower GI bleeding.
Correlate issues learned in ther
modules like shock due to hemorrhage, or burns.
When is the bleeding
considered massive? Assessment of blood loss.
Review replacement and
maintenance of blood volume.
When do we call in the surgeon?
Why do we
have to call a surgeon?
What about endoscopist?
Paraclinical diagnostic
procedures
Indications, accuracy,
complications
Trigger 4
The following
laboratories were ordered by the admitting physician:
CBC, CT, BT, blood
typing, platelet count
ECG 12 leads
FBS, creatinine, uric acid,
cholesterol, triglycerides
Fecalysis
Occult blood
The patient was
hooked with an IV fluid and blood was requested.
Medications given
included:
Nifedipine 5 mg. SL
Tranexamic acid 500 mg IVTT now then 500
mg capsule 3 x a day
Orders for monitoring the amount and frequency of
hematochezia.
On referral to the department of surgery on the same
day, the following laboratories were ordered:
Barium enema - Show
the X-ray plates of this
patient
Prompt the student to interpret
it
Review with them how to identify Colon from Intestines
|
Questions for Tutors:
1. Comment on the paraclinicals
ordered. Suggest a rationale for each.
2. What would you have done in this
case?
3. What is tranexamic acid? Its action and side effects, if
any. |
Learning Goals
1. Rational use of paraclinicals
tests
Occult blood in stools,
significance.
Specificity and accuracy of such
test. e.g. false negative
2. Action, indications and side effects of
tranexamic acid and other hemostatic
agents.
Laboratories
Results
CBC
FBS =
4.0
Hgb
8
BUN =
7
Hct
24
Creatinine =
80
WBC 5000 x 10
Uric acid =
220
neutrophils
.60
Cholesterol =
NA
lymphocytes.20
Triglycerides =
NA
CT
normal
BT
normal
Platelet 250,000
Chest x-ray : Atheromatous aorta
residual lung
fibrosis
Barium enema ; Multiple diverticulosis with occasional
signs of spasticity.
Incidentally pelvic cavity calcification. Merits
ultrasound correlation.
(plates available for viewing at the deans office).
Request the students to rationalize how air-contrast media radiology is achieved
and its rationale.
Ultrasound, pelvis : Uterus is small measuring
4.6 x 2.2 x 1.7 c and is normal with the age of the patient. Endometrial stripe
is intact.
No adnexal mass seen.
Impression ; Normal uterus and
adnexa.
ECG : within normal limits
|
Prompts for the Tutors:
1. Review the case. Ask
the student to make a brief summary of the case, or an algorithm.
2. Give
feedback on their summary( if they are focused, brief and concise.)
3. Ask
them to interpret the lab. results and how it helped them in their impression of
the case so far.
4. Inquire students on the modality of treatment for this
patient. Are there other options? Advantages and disadvantages of one option
over the other in terms of risks and complications.
5. How would they advise
this patient regarding treatment. How would you treat the anemia here?
6. If
the diverticulitis were not that extensive, would the treatment approach
differ?
7. Why did this patient have no abdominal pain symptoms in the past
considering she has a very extensive multiple diverticulosis?
8. Does
diverticulosis aftect digestion and absorption of nutrients?
9. What is the
relationship between diverticulosis and the intestinal gut flora?
10. Why was
a pelvic examination/ultrasound done here? was it
indicated? |
Learning Goals
1. Rational, logical approach to a
diagnosis - diverticulosis
2. Advice about treatment and treatment
modalities.
3. Etiopathology of diverticulitis. How do they come about?
4.
Complications of diverticulosis
Trigger 5
The patient
underwent exploratory laparotomy with resection of the descending colon,
tranverse colon and the distal descending colon with primary anastomosis. The
calcification in the pelvis turned out to be serosal myomas which were
excised.
The patient had a stormy postoperative course but eventually
improved and was discharged well. The patient is now still alive and doing
well.
|
Tutors Prompt
Post operatively. what complications
do you antecepate after surgery?
e.g. Vit B12 absorption and others.
Can
this surgical resection affect fat digestion and absorption
postoperatively?
How?
How would you care for the nutrition of this
patient? |
Trigger 6 : Behavioral and Population
Perspective
1. This experience of seeing blood in the stools is very
frightening to the patient . Even more so the fact to be told that she has to
undergo resection of the entire colon practically.
What possible concern
do you think the patient has? How can you help her verbalize these?
How would
you address these concerns?
How far should you go to support this
patient?
What is the limit of your role?
2. How common is GIT
bleeding? Which group of population are susceptible to this syndrome?
Why?
3. Are there any risk factors that you can think of that may be
forerunners to GIT bleeding ? Health habits or behavior? How would you address
them?
|
