1. 2/3/2010
Abdullah Al-Abdali
R2 EM
Outline
Case discussion
Clinical approach to such cases
1
2. 2/3/2010
82 years old female, presented with:
Bloody diarrhea with fresh blood
Abdominal pain
hematurea
primary survey
vital signs
2
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. 2/3/2010
Intervention ??
NS boluses
Blood ordered, 6U
Post resuscitation
P:92
BP:100/60
Sat:100% on 100% O2
4
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. 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. 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. 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. 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. 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. 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
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. 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. 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
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