young_doc
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7. A 61-year-old woman comes to the emergency department because of massive bleeding from the rectum. She has experienced multiple episodes of frequent, large, red stools, without abdominal pain. She has no chest pain, but is short of breath.
On physical examination, her pulse rate is 130/min, respiration rate is 24/min, and blood pressure is 90/50 mm Hg. Cardiac examination discloses tachycardia with a regular rhythm. The lungs are clear. The abdomen is nontender, with hyperactive bowel sounds. Rectal examination discloses only red blood. A nasogastric tube is placed, and lavage returns yellow fluid that is negative for blood, but positive for bile.
In addition to fluid resuscitation, which of the following interventions should be done next?
A. Arteriography
B. Colonscopy
C. Upper endoscopy
D. Capsule Endoscopy
E. Radionuclide bleeding scan
Edited by young_doc on 04/23/07 - 06:42 PM
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| sprint123
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Colonoscopy to find out the exact site of bleeding----If it doesn't reveal any site,then nuclear scan...
Answer b....
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| Justice
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E. Radionuclide bleeding scan
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| Justice
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I am guided by the following:
http://www.pubmedcentral.nih.gov/articlerender.fc...
Evaluation and management of massive lower gastrointestinal hemorrhage.
I M Leitman, D E Paull, and G T Shires, 3rd
Department of Surgery, New York Hospital-Cornell Medical Center, New York 10021.
Small right arrow pointing to: This article has been cited by other articles in PMC.
Abstract
Sixty-eight patients with massive lower gastrointestinal (G.I.) hemorrhage underwent emergency arteriography. Patients were transfused an average of six units of packed red blood cells within 24 hours of admission. The bleeding source was localized arteriographically in 27 (40%), with a sensitivity of 65% among patients requiring emergency resection. However, twelve of the 41 patients with a negative arteriogram still required emergency intestinal resection for continued hemorrhage. Radionuclide bleeding scans had a sensitivity of 86%. The right colon was the most common site of bleeding (35%). Diverticulosis and arteriovenous malformation were the most common etiologies. Selective intra-arterial infusion of vasopressin and embolization were successful in 36% of cases in which they were employed and contributed to fatality in two patients. Twenty-three patients underwent segmental resection, whereas seven patients required subtotal colectomy for multiple bleeding sites or negative studies in the face continued hemorrhage. Intraoperative infusion of methylene blue via angiographic catheters allowed successful localization and resection of bleeding small bowel segments in three patients. Overall mortality was 21%. The mortality for patients without a malignancy, with a positive preoperative arteriogram, and emergency segmental resection was 13%.
It appears that (E) has the highest sensitivity
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| dr.wad
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the colon will be full of bood , making visualization of the colon difficult with colonoscopy.
so E. Radionuclide bleeding scan is the best investigation in this case.
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| vradojc1
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E - as dr Wad says.
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| sprint123
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i THINK We can't assume colon to be full of blood as the source might be only from rectum...
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| Justice
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dr.wad & vradojc1,
I am glad that we think similarly...
The Pt is still bleading, and it would be very hard to see the site of bleeding... But, do we need to consider the option (B) Colonscopy which could be used to stop bleeding? (E) just does not have this benefit... What do you think?
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| Justice
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sprint123 wrote:
i THINK We can't assume colon to be full of blood as the source might be only from rectum...
The Pt has experienced multiple episodes of frequent, large, red stools... If the bleeding is rectal, the stool won't be large, will it? I am a bit confused...
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| vradojc1
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Rectal bleeding will not increase volume of the stools.
She is in the state of shock having lost >30% of her blood (Systolic BP<100 and HR >100) so it should mean around 1.3L. I actually think angiography (arteriography) should be the next step with her rate of bleeding since we could perform embolization right away.
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| vradojc1
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Especially knowing the duration of the radionuclide scan (60-90 min), she might die in the scanner. However, I'm always a bit confused with terms that don't completely match with the ones that are used more commonly (here arterio- vs angiography).
I think I'd think twice on this q before posting an answer, but as of now, I think it's rather A.
What is the answer young_doc?
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| radonc
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I think it's B. Colonoscopy.
The commonest causes of massive rectal bleeding are angiodysplasia and diverticular disease. Haemorrhoids does not usually cause massive rectal bleeding. Note that massive rectal bleeding is not the same as just finding some blood in your stools.
Following fluid resuscitation, she should undergo colonoscopy. If the lesion is seen, you may be able to cauterise it, eg angiodysplastic lesion. In some cases, you cannot identify the lesion, then need to do RBC radionuclide study to see where she is bleeding from. I think angiography should be last resort for management of massive PR bleed.
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| vradojc1
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From CMDT 2007:
"Colonoscopy
In those patients with stable vital signs whose lower gastrointestinal bleeding appears to have stopped (ie, no rectal bleeding within 4 hours of evaluation), elective colonoscopy should be performed to determine the probable site of bleeding within 24 hours of admission after adequate resuscitation and routine colonic lavage. For patients with signs of severe or active lower gastrointestinal bleeding (defined as pulse 100 beats/min or higher, systolic blood pressure < 100 mm Hg), urgent colonoscopy is performed within 6–12 hours of admission after administration of a rapid, high-volume colonic lavage solution, given until the effluent is clear of blood and clots (GoLYTELY, CoLYTE, NuLYTE, 4–8 L given orally or by nasogastric tube over 3–5 hours). At urgent colonoscopy, the probable site of bleeding can be identified in 70–85% of patients, and a high-risk lesion can be identified and treated in up to 20%. Alternatively, many physicians choose first to obtain a nuclear bleeding scan to determine whether there is active bleeding. If no bleeding is detected on the scan, a colonoscopy should be done. If bleeding is detected, angiography should be performed.
Nuclear Bleeding Scans and Angiography
Significant continued bleeding occurs in only 15% of patients but may limit the diagnostic effectiveness of colonoscopy. In such patients, either angiographic embolization or surgery may become necessary to control the bleeding. Technetium-labeled red blood cell scanning can detect significant active bleeding and localize it to the small intestine, right colon, or left colon. Because bleeding may be slow or intermittent, less than half of studies are diagnostic, and the accuracy of a positive study is only 78%. Nuclear bleeding studies are more apt to be positive in patients who are passing bright red or maroon stools at the time of the scan. Selective mesenteric angiography requires more brisk bleeding (0.5–1 mL/min) for a positive result than technetium scans and leads to major complications in up to 3% of patients. Accordingly, angiograms are performed only in patients with positive technetium scans or with hemodynamically significant, ongoing bleeding. Localization of an actively bleeding vessel is possible in up to 80%."
2007 Current Consult: Medicine
"Diagnosis
Laboratory Tests
Complete blood cell count, platelet count, prothrombin time, INR
Serum creatinine, blood urea nitrogen
Type and cross-match
Imaging Studies
Nuclear technetium-labeled red blood cell scan in patients with massive bleeding
Selective mesenteric angiography in patients with massive bleeding or positive technetium scans
Diagnostic Procedures
Nasogastric tube aspiration to exclude upper tract source
Anoscopy
Colonoscopy in patients in whom bleeding has ceased or in patients with moderate active bleeding immediately after rapid purge with 4–12 L polyethylene glycol solution to clear colon (rapid purge colonoscopy)
Small intestine push enteroscopy or video capsule imaging in patients with unexplained recurrent hemorrhage of obscure origin, suspected from the small intestine
Upper endoscopy in massive hemotochezia to exclude upper GI source"
Tintinalli Emergency medicine:
"Diagnostic Studies
Routine abdominal radiographs are often obtained in patients with GI bleeding. In the absence of specific indications, they are of limited value. Similarly, routine admission chest x-rays for patients with acute GI hemorrhage, even those admitted to the intensive care unit, have been shown to be of limited utility in the absence of known pulmonary disease or abnormal findings on lung examination.5 Barium contrast studies similarly are of limited diagnostic value in an emergency setting. Further, barium limits the use of subsequent endoscopy or angiography.
Angiography sometimes can detect the site of bleeding, particularly in cases of obscure lower tract hemorrhage. Moreover, angiography permits therapeutic options such as transcatheter arterial embolization or the infusion of vasoconstrictive agents. However, to be diagnostic, angiography requires a relatively brisk bleeding rate (0.5 to 2.0 mL per min).
Technetium-labeled red cell scans also have been used to localize the site of bleeding in obscure hemorrhage. Such localization can be used to map the therapeutic approach, whether via angiography or operatively. Scintigraphy appears more sensitive than angiography and can localize the site of bleeding at a rate of 0.1 mL per min.
Another approach is colonoscopy, which may be not only diagnostic but, through the use of endoscopic hemostasis, also therapeutic. In most circumstances, endoscopy is more accurate than arteriography or scintigraphy.
Controversy in the literature remains as to whether scintigraphy, angiography, or colonoscopy, and in which order, should be the initial diagnostic procedure of choice in the evaluation of lower GI bleeding.6–9 Thus, these decisions are often based on local availability and consultant preference."
In the attachment various algorithms from recent literature.
Obviously no consensus.
Attached Files:
Schwartz's Surgery Algorithm.pdf (332 KB, 0 downloads)
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| vradojc1
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More attachments
Attached Files:
Harrison's Algorithm.pdf (49 KB, 2 downloads)
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| vradojc1
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And more
Attached Files:
Hall Principles of Critical Care Algorithm.pdf (70 KB, 0 downloads)
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| vradojc1
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and more
Attached Files:
Current Surgery Algorithm.pdf (35 KB, 0 downloads)
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| vradojc1
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And more
Attached Files:
Cecil's Algorithm.pdf (45 KB, 0 downloads)
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| vradojc1
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Again my two cents, she is still bleeding (red blood on rectal exam) so I doubt that even extensive colonic cleaning would enable us to see clearly what's inside. Since it is high volume bleed (as described before), and as said she is still bleeding, I'd do angio and try to do embolization at the same time.
But that is individual approach.
Then again, let's see whether every US hospital has capability of running nuclear medicine scans? I would say all of them have interventional radiologists (embolization)?
It's a mess, if the "great minds" cannot agree, what does USMLE expect from us?
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| doc_clotaire
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STEP by STEP Guys !
which of the following interventions should be done next?
I would pick B ( Colonoscopy )
if not seen in Colonoscopy then :
E ) E. Radionuclide bleeding scan ( for active bleeding that cannot be localized by colonoscopy )
That 's my humble opinion ! Let 's see what's popping  ?
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| vradojc1
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It's me again.
So, situation is clear in bleeding that has stopped and that didn't cause significant blood loss (or that is still active but minimal).
However, when bleeding is massive as here, we have no firm guidelines. What I'm trying to say is even when young_doc provides us with an answer it doesn't necessarily mean that the answer is correct for the purposes of the actual exam.
The writers of the UW/Kaplan banks are not the ones composing the actual exam and due to the lack of consensus in profession, any of the three (angio/colonoscopy/radionuclide scan) can be correct.
That is what I tried to stress in the end of my last post. So, let's hope that if we get any GI bleeding q it is going to be more straightforward.
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