Acute lower gastrointestinal bleeding
Although endoscopic therapy has proved to be efficacious in the management of upper gastrointestinal (UGI) bleeding, its role in acute lower gastrointestinal (LGI) bleeding continues to be controversial. There are numerous reasons for the controversy. Most published data evaluating LGI bleeding are derived from case series completed in tertiary-care centres that combine patients with mild, moderate and severe LGI bleeding. This limits the applicability of these findings to smaller centres and individual patients because these data may not apply to regions where endoscopists are not routinely exposed to acute LGI bleeding. In addition, management protocols clearly should vary depending on the severity of bleeding. Colonoscopic examinations in severe, acute LGI bleeding may be difficult to perform due to blood that obscures the mucosa as it refluxes throughout the colon, even if it originates from a distal site. Alternatives for diagnosis and therapy include radiological and surgical interventions, which are often used for acute, severe hemorrhage but carry considerable morbidity and mortality. Despite numerous advances in diagnostic strategies over the past several decades, as many as 8% to 12% of patients with acute, severe LGI bleeding still undergo surgery without localization of the bleeding site. Up to 33% of patients continue to bleed postoperatively. Furthermore, LGI bleeding tends to be intermittent, with 85% of patients undergoing spontaneous cessation; this creates difficulty in assessing clinical outcomes because the majority of patients stop bleeding regardless of therapeutic intervention. Finally, ready access to emergency colonoscopy is not universal, and with ever-tighter financial constraints, endoscopy units are under increased pressure to meet budgetary demands by restricting the number of endoscopic procedures. This pressure may encourage some gastroenterologists (who would otherwise use emergency endoscopy) to opt instead for an alternative mode of investigation and management. This is your great chance – buy levaquin 750 mg to take full advantage of best quality drugs.
Although consensus guidelines, and recommendations for investigation and management of LGI bleeding exist, there is no universally accepted method that applies to all patients. The present article offers a review of the published literature in an effort to assist endoscopists with their management of patients with LGI bleeding, with an emphasis on assessment and treatment of massive LGI bleeding, and to develop further practice guidelines for management.
The most important initial step in assessing a patient with LGI bleeding is the history and physical examination. Clearly, the accurate, expedient assessment of the airway, breathing and circulation guides the speed at which resuscitation is initiated. At times, the clinical presentation of UGI bleeding can be identical to that of LGI bleeding; therefore, use of nonsteroidal anti-inflammatory drugs, or a history of peptic ulcer disease, dyspepsia or liver disease may dramatically change the sequence of investigations. Similarly, a change of bowel habits, anorectal complaints or a history of hematochezia can alter the course of investigations if noted. The assessment of hemodynamic stability and the estimation of the amount of blood loss are the next steps. Adequate intravenous access of crystalloid and colloid should be administered to all patients with suspected moderate or massive gastrointestinal bleeding. If there is any suspicion of UGI bleeding resulting in hematochezia, insertion of a nasogastric tube or even an upper endoscopy may be warranted to identify the bleeding site. In certain instances, proctoscopic examination is indicated for the assessment and subsequent treatment of hemorrhoids, which occasionally can present with severe bleeding.