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GI Bleeds and Colon

1. ¾ cases originate in upper GI tract. Young patients are most likely to have upper GI
bleeds, elderly patients are “equal opportunity bleeders.”
a. GI bleeds of the colon can be due to angiodysplasia, polyps, diverticulosis,
cancer, or hemorrhoids
2. Work up for bleeding per rectum
a. First, give IV fluids and correct any electrolyte abnormalities.
b. If patient is actively bleeding, pass an NG tube and aspirate gastric contents.
i. If fluid is white, then the tip of the nose to pylorus has been excluded
ii. If fluid is green, then the tip of nose to ligament of Treitz has been exclude
and there is no need for an upper GI endoscopy.
c. Follow with an upper GI endoscopy. If not actively bleeding and elderly, do lower
GI endoscopy at the same time.
d. When upper GI bleed is excluded, rule out bleeding hemorrhoids with an
anoscopy. Colonoscopies are not helpful during active bleeding.
i. If bleeding exceeds 2mL/min, do an angiogram because it may allow for
any necessary embolization
ii. If bleeding is less than 0.5m/L/min, wait until the bleeding stops and do a
colonoscopy.
iii. For bleeding rates in between, do a tagged red cell study. If the RBCs
collect somewhere, it may be worth doing an angiogram. However, this
test is very slow and the bleeding may stop before an angiogram can be
done.
1. Even if the bleed stops, the tagged RBC study gives an idea of if
the bleeding is on the right or the left, so a “blind” hemicolectomy
can be done in the future.
2. If tagged red cells do not show up, a subsequent colonoscopy is
planned.
3. Flexible proctosigmoidoscopies can be done without sedation.
3. Diseases Specific to the Colon
a. Cancer of the right colon
i. Typically shows up with anemia in the elderly. Stools will be 4+ for occult
blood. Colonscopy and biopsies are diagnostic, and treatment is a right
hemicolectomy
b. Cancer of the left colon
i. Shows up with bloody bowel movements +/- constipation or narrow
caliber.
ii. Diagnosed with a flexible proctosigmoidoscopic exam with biopsy.
iii. Before surgery, perform a full colonoscopy to rule out a synchronous
second primary
iv. CT scan helps assess operability and extent.
v. If large, pre-op chemo and radiation may be necessary
c. Colonic polyps may be premalignant

Only surgically treated when there are bleeds. Both can produce severe diarrhea with blood and mucus ii. need for high-dose steroids/immunosuppressants. but results in the need for a stoma or ileoanal anastomosis. . strictures. Crohn’s can occur in multiple GI locations. Peutz-Jeghers. People with FAP are 100% likely to develop colorectal carcinoma. ii. Indications include active disease for more than 20 years. Familial polyposis. isolated inflammatory. severe nutritional depletion. or fistulas iii. Crohn’s Disease and chronic ulcerative colitis i. so resection is not curative. Juvenile polpys. multiple hospitalizations. i. familial multiple inflammatory polyps. or development of toxic megacolon. and adenomatous polps are likely to become malignant 1. Perform a colectomy. d. Chronic ulcerative colitis can be surgically cured. 1. villous adenoma. and hyperplastic polpys are not premalignant.