- Upper GI vs Lower GI (distal to ligament of Treitz)
Differential diagnosis
- Anorectal: Hemorrhoid, Fissure, Proctitis, Cancer of rectum, Polyp, Fistula
- Vascular: ischemia, angiodysplasia
- Inflammatory: Inflammatory bowel disease
- Infectious: Shigella, Salmonella, E.coli, C.diff, Campylobacter, H pylori
- Neoplasm
- Congenital: Meckel’s
- Structural: intussusception, polyps, diverticuli
- Clotting disorders
HPI
- Bleeding
- OLDSCARS
- What circumstances?
- How much blood?
- Tarry, mixed in, on paper
- Melena? Fe, peptobismol, beets, licorice
- Previous bleeding?
- Infection: nausea, vomitting, fevers/chills, diaphoresis
- Anemia: vertigo/lightheaded, pale, weakness
- Urgency, tenesmus, anal pain
- B-symptoms (weight loss, fever, night sweats)
- Bowel history: polyps, hemorroids, inflammatory bowel disease (IBD), ulcers, cancer, regularity, fissure
Past Medical History– clotting disorder, radiation, coronary artery disease, abdominal aortic anuerysm, H pylori, Gyne history
Family history – bowel cancer, IBD
Medications – NSAIDs, anticoagulants, iron, steroids
Social History: smoking, alcohol use
Physical Exam
- General appearance
- Vitals: blood pressure, tachycardia, orthostatic changes, temp, respiratory rate
- Skin: jaundice, liver disease stigmata, ecchymosis, petechiae
- Mucous membranes
- Abdomen: distension, caput medusa, bowel sounds, tenderness, masses, ascites, hepatosplenomegaly
- Rectal: stool, haemorrhoids, rectal mass, fissure, fistula
Laboratory
- Type and Crossmatch
- CBCD, lytes, BUN, Cr
- PT/PTT, LFTs
Imaging
- Rigid sigmoidoscope
- Colonoscopy (Family history of bowel cancer, >50 y.o., bleeding, mucous, stools changes)
- Barium enema
- Gastroscopy
- Angiography (Tc labelled RBC scan if indicated)
Management
- Stabilize hemodynamically (2 large bore IVs, crystalloid, RBCs, foley, NG tube)
- Monitor for ongoing blood loss (vitals, labs, CVP)
|
Chracteristic |
UC |
Crohn’s |
|
Course |
Exacerbations and remissions |
Smouldering |
|
Bleed |
Always |
Uncommon |
|
Abdo pain |
Uncommon |
Common |
|
Perianal |
Rare |
Up to 40% |
|
Fistulas |
Never |
Occasional |
|
Abdo mass |
Never |
Occasional |
|
Rectal involvement |
Always |
Spared |
|
Distribution |
Uniform, confluent |
Skip lesions, eccentric |
|
SB |
Spared |
Often |
|
Strictures |
Rare, malignant |
Frequent, benign |
|
Mucosa |
Shallow ulcers, bleed, pseudopolyps |
Longitudinal ulcers, fissures, cobblestone |
|
Extent |
Mucosa, submucosa |
Transmural |
|
Granuloma |
Never |
Always |
|
Dysplasia |
Yes |
Yes |
|
LN |
REactive |
With granulomas |
|
Crypt abscess |
Yes |
Yes |
|
Mucous |
Less |
More |
|
Cancer |
30% at 25 yrs |
Longer duration |
- Extraintestinal: PSC, psoriasis, RA/AS (UC); colitic arthritis (Crohn’s): erythema nodosum, pyoderma gangrenosum, cholelithiasis (decreased bile salt absorption in distal ileum)
- Treatment: steroids, 5-ASA, immunosuppressants, surgery (UC)