MHP
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To localize the source of hematochezia in a 70-year-old man, which one of the following is the most appropriate sequence of diagnostic tests?
a). Barium enema, nasogastric intubation, sigmoidoscopy
b). Nasogastric intubation, colonoscopy, angiography
c). Rectal examination, angiography, sigmoidoscopy
d). Colonoscopy, gastroscopy, CT scan of the abdomen
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| prathapdoctor
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nasogastric intubation,colonoscopy and angiography.
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| young_doc
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hematochezia is bright red blood in the stool....So i wouldn't suggest doing a nasogastric intubation first since it's a lower GI bleed.
C. Rectal exam. Angiography. Sigmoidoscopy.
(My 2 cents. Correct me if i'm wrong!)
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| fox
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Agree with young doc, but choice C would have been better if Sigmoidoscopy was b4 angio
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| Aashi
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Although lower GI bleed is seen MORE commonly in elderly,that doesnt mean that they cant have a UPPER GI bleed,85% irrespective of wether they are young or old,upper G.I source stands by far the MCC of GI bleed..So first we rule out Upper G.I bleed,By introducing NG tube,if bile positive..stop work up there,and go from down.
Abt angio following colonscopy,that is the only catch here..y shld one even go for colono if ur going to angio finally ,coz angio per se is done when someone is bleeding heavily coz the bleed doesnt allow to see through the scope OR WHEN YOU CANT IDENTIFY THE SOURCE..Since the q doesnt tell u the AMOUNT of bleed,its better we DONT ASSUME that this pt is bleedin heavily,coz we dont have a choice in the answer which says NG TUBE,THEN ANGIO ...so probably this guy is having minimal bleed ,wer u can safely put in a colonoscopy first after ruling out first upper GI bleed with NG and still u cant find source after doing a colonscopy, then u do angio after that.
So I go for B--->b). Nasogastric intubation, colonoscopy, angiography
GL
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| doc_clotaire
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I guess the answer is B
1 ) nasogastric intubation : to find out uppper GI bleed because some MASSIVE GI BLEEDING can also cause hematochezia but the patient would present some systemic signs of hypovolemic shock
2 ) Colonoscpy : Best Dx test in hematochezia
3 ) Angiography : for massive bleeding that cannot be localized by colonoscopy
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| young_doc
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point taken...but an upper GI bleed is HIGHLY unlikely to give bright red blood!!!
Actually another reason why i chose C, is because regardless of whether we haev hematochezia or melena...a Rectal Exam in my opinion should always be the first thing we do!!!..right?
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| prathapdoctor
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actually in harrison whats given is - he divided patients with GI bleed in to 2 categories,in one category patients with GI bleed with unstable hemodynamics and others are stable hemodynamically.
what he said is,if the patient is stable - then go to colonoscopy first,if the patient is not stable first do endoscopy then go for colonoscopy.
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| lilla
Forum Senior
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I go for D. for old patient the most commonly bleeding is diverticulosis and colonoscopy is the most accurate test.
what is the right answer?
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| liwei
Forum Junior
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is that an active bleeding? If so, colonscopy would not be the ist choice.
rectal exam is a part of PE, should go first
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| webjeee
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b
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| Mahwish Mushtaq
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B what's the right answer
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| DrPak
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I think its none of the answers really fit the bill. The correct management to lower GI bleed is:
1. rectal exam to check for hemorrhoids which is the most common cause of lower GI bleeds... if no hemorrhoids found, then
2. NG tube to check for upper GI bleed.... it only takes a few seconds to check and is less invasive than...
3. Sigmoidoscopy/colonoscopy to look for angiodysplasia and diverticulosis which are the 2nd and 3rd most common causes of lower GI bleeding.
I think the question is poorly structured with none of the answer choices being ideal.
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| Dr.Luck
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yes, I agree with dr.pak but do add upper endoscopy after NG tube b/c bg tube checks uptil the pylorus but the upp endoscopy will check uptil 2nd part of duodenum(which is above the ligament of treitz & may be the source of up GI bleed)
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