Gastrointestinal Bleeding
INVESTIGATIONS—SPECIFIC Sigmoidoscopy
• Useful primarily in patients < 40 years of age for minor bleeding due to low-lying anal disease.
Colonoscopy5,6
• First procedure of choice in LGI bleeding diagnosis; may be performed urgently or electively depending on patient’s hemodyna-mic status and risk-stratification criteria such as positive FOBT in patient > 40 years of age
• Though colonoscopy is recommended for patients with LGI bleeding, it may also be used in combination with EGD (i.e. bidirectional endoscopy) for patients with upper GI bleeding, OGIB, or nondiagnostic EGD
• Advantages include: direct visualization; access for tissue biopsy (Bx), and ability to treat bleeding lesions primarily with heat probe, laser therapy, band ligation, or hemoclipping.
Angiography (Mesenteric)
• Used for active, heavy bleeding and/or if colonoscopy is inconclusive
• The main advantage include: accurate localization of bleeding sites that are not identified by endoscopy
• It may also permit therapeutic interventions, e.g. vasopressin infusion and embolization.
Complications such as renal failure, rebleeding may occur.
Multidetector Computed Tomographic (MDCT) Angiography7-9
• MDCT angiography is a promising first-line modality for fast and accurate localization of acute GI and intraperitoneal bleeding.
99mTc RBC Scanning
• Like angiography, it is only of value in patients with active bleeding. The newer techniques involving dynamic imaging (more frequent acquisition of data), extra large field-of-view gamma cameras, and cine scintigraphy, or movie-mode displays have proved to have an accuracy of nearly 90% in the localization of the bleeding site
• Also most often employed in confirming Meckel’s diverticulum.
Abdomen US/HRCT
• May be indicated to diagnose associated disorders such as pancreatitis, aortic aneurysm, ascites, metastasis, and aortic graft infection.
Double-contrast Barium Enema
• May be an alternative in patients with contraindications to colonoscopy.
Small Bowel Imaging
• When endoscopy is undiagnostic, the small bowel is evaluated. Common procedures employed are contrast radiography, i.e. UGI barium follow-through series, and push enteroscopy, which is an extension of EGD that allows visualization up to 160 cm. of small bowel distal to ligament of Treitz; allows tissue biopsy (Bx), and treatment of bleeding lesions up to 160 cm. of the proximal small bowel.
Capsule Endoscopy10,11
• It is a noninvasive visual evaluation of the entire small bowel and esophagus, indicated in:
Suspected small intestinal bleeding in persons with objective evidence of recurrent, obscure gastrointestinal bleeding (e.g. iron-deficiency anemia, positive fecal occult blood test, or visible bleeding) who have had EGD and colonoscopy within the past 12 months that have failed to identify a bleeding source.
Diagnosis: A Symptom-based Approach in Internal Medicine 150
For initial diagnosis in persons with suspected Crohn’s disease without evidence of disease on conventional diagnostic tests, including small-bowel follow-through and upper and lower endoscopy.
For screening or surveillance of Barrett’s esophagus, and esophageal varices.
Echocardiography
• There is a well-recognized association between angiodysplasia and aortic stenosis and replacement of the stenotic valve has been reported to stop GI bleed in over 90%
of patients. Echocardiography should therefore be a part of the investigations in such cases.12-14
Laparotomy with Intraoperative Enteroscopy
• A last option in the diagnostic evaluation of nonemergent cases.
CLINICAL NOTES
• Confirm hematemesis; patients often confuse vomiting up and coughing up blood. A history of epistaxis, bleeding gum disorders, hemo-ptysis indicate sources other than GI tract.
Ideally viewing the vomit is the best way to confirm hematemesis
• Confirm melena; black stools may result from ingestion of iron salts, charcoal, beets, etc.
• Patients with severe bleeding may present with signs of shock (tachypnea, tachycardia, hypotension; systolic blood pressure
<100 mm Hg usually indicates <30%
reduction in blood volume), which in patients with co-morbid disease such as IHD may precipitate angina or MI because of hypoperfusion. However, resuscitative measures and appropriate level of patient monitoring must be established before diagnostic testing or specific therapeutic interventions
• Nasogastric lavage should be performed in patients with UGI bleeding. Nasogastric lavage may be useful as a diagnostic technique. A bloody lavage may be helpful in predicting a high-risk lesion, particularly in hemodynamically stable patients without hematemesis; a clear lavage may be helpful in predicting low-risk lesions. Nasogastric lavage can also facilitate endoscopic visualization by clearing blood and other gastric contents. A negative lavage, however, does not exclude upper GI bleeding; the procedure carries a false-negative rate of 10%.
The bleeding in such cases may be intermittent or located in the duodenum.
Aspiration of bilious, nonbloody material strongly indicates that no active duodenal bleeding is occurring15, 16
• In UGI bleeding important historical information should include the onset, character, frequency, and quantity of hematemesis. Peptic ulcer pain is epigastric, gnawing, rhythmic, and dull. GI malignancy is associated with vague epigastric pain, dyspepsia, or weight loss. Coughing, retching, or vomiting preceding hemate-mesis suggest MW tears
• Although LGI bleeding is usually painless, a history of abdominal pain, weight loss, fever, diarrhea, vomiting, or partial small intestinal or colonic obstruction are important findings in the differential diagnosis of inflammatory, infectious, or malignant lesions. Diverticular disease presents as painless with high volume bleeding. Cancer and angiodysplasia present with symptoms of chronic blood loss (anemia, fatigue, dyspnea on exertion)
• History of prior GI or vascular surgery, e.g.
aortic bypass, and history of any comorbid disease such as pancreatitis, cirrhosis, renal failure, cancer, etc. precipitates hematemesis
Gastrointestinal Bleeding 151
• A history of cutaneous bleeding (e.g.
purpura, ecchymosis) may indicate bleeding diathesis (e.g. hemophilia, hepatic failure)
• Age is an important feature in discrimi-nating the source of LGI bleeding. For patients aged more than 50 years, ischemia, colonic AV malformation, diverticulosis, and malignancy are most common17
• Colonic AV malformations are most commonly found in the cecum, often associated with several systemic diseases, including atherosclerotic cardiovascular disease, aortic stenosis (Heyde’s syndrome), chronic renal disease, collagen vascular disease, von Willebrand disease, and cirrhosis of the liver
• Medications—NSAIDs, steroids, and use of recreational drugs, cigarettes, or alcohol increase the incidence of erosive gastritis or ulcer disease
• Because of increasing number of elective aortic aneurysm repairs in the aging population, it is likely that more patients with secondary aortoenteric fistula will present with LGI bleeding. Hence, a high index of suspicion is necessary for prompt diagnosis and management of this life-threatening event
• The clinical findings of initial physical examination and their possible etiologies are given in Table 22.3.
RED FLAGS
• It is crucial to remember that identification of a benign anorectal lesion (hemorrhoids, ulcer, etc.) does not eliminate the possibility of a more proximal cause of hemorrhage. In general, patients with hemorrhoids identified by physical examination should still undergo thorough endoscopic evaluation of the colon to rule out other pathological conditions (e.g. portal hypertension, anorectal varices, etc.).
• Positive FOBT may be the first sign of colon cancer or polyp, particularly in patients above 45 years of age
• Solitary rectal ulcer syndrome should be considered in all patients with malignant looking rectal tumors
• Aortoenteric fistula must be suspected in any patient presenting with UGI bleeding with known aortic graft (e.g. prior aortic aneurysm repair). Urgent diagnosis and surgery is mandatory to prevent exsanguinating hemorrhage
• Most commonly missed OGIB disorders related to UGI segment are: erosions in large hiatal hernias; AV malformations, and peptic ulcer on the first endoscopic evaluation
• The LGI lesions most commonly missed on initial endoscopy are: AV malformations and neoplasms. Repeat upper, lower, or
bidirec-Table 22.3: Physical examination in GI bleeding General or system Etiologies
• Systemic disease
• Significant blood loss
• IBD
Peutz-Jeghers syndrome: vide infra ↓↓
• Ectopic bleeding source-? present
• Volume status
HIV, leukemia, metastasis
• Angiodysplasia associated with aortic stenosis
• Volume status
• PUD; H. pylori
Cirrhosis of the liver; malignancy Crohn’s disease; malignancy Aortic aneurysm
• Fissure; hemorrhoids; mass
• Bright red or ‘coffee-ground’
in UGI bleeding; positive for blood
• Weight loss; cachexia
• Vitals—Pulse-tachycardia, – low volume;
– BP—hypotension
• Skin and mucous membrane:
Erythema nodosum Jaundice
Pallor; ecchymosis Cutaneous telangiectasis Pigmented macules on the lips
• Nose and oral cavity
• Neck: JVP Lymph nodes
• Cardia: Murmurs
• Lungs: Basal rales/ crepitations
• Abdomen:
• Rectal examination:
• Nasogastric aspirate
Diagnosis: A Symptom-based Approach in Internal Medicine 152
tional endoscopy may be essential depen-ding on clinical suspicion, and to ascertain that these lesions have not been overlooked.
SELECTIVE GLOSSARY
Dieulafoy’s lesion—It is an abnormally large artery that penetrates the gut wall, mainly in the proximal stomach, causing massive bleeding.
The lesion bleeds into the GI tract through a minute defect in the mucosa, which is not a primary ulcer of the mucosa, but erosion probably caused on the submucosal surface by the pulsatile arteriole protruding into the mucosa. Dieulafoy’s lesion is most commonly located in the proximal stomach (75% of cases).
Lesion typically occurs within 6 to 10 cm of the esophagogastric junction, generally along the lesser curvature of the stomach. Detection and identification of the Dieulafoy’s lesion as the source of bleeding can often be difficult, especially because most present with massive bleeding. Because of intermittent nature of bleeding, initial endoscopy is diagnostic in 60%
of the cases, so repeated endoscopies are often necessary. Similar lesions have been identified in the duodenal bulb, jejunum, ileum, colorectum, anal canal, and even in bronchus. With the advances in endoscopy and awareness of Dieulafoy’s lesion as the cause of massive bleeding that can causea high fatality rate if the condition remains unrecognized, it has gained the reputation of an unusual but important cause of bleeding, especially LGI hemorrhage.
Hereditary hemorrhagic telangiectasia (HHT / Rendu-Osler-Weber Syndrome)—It is a hereditary disease of vascular malformation transmitted as an autosomal dominant trait affecting men and women, characterized by the presence of multiple arteriovenous malformations (AVMs) that lack intervening capillaries and result in direct connections between arteries and veins.
Small AVMs (or telangiectases) close to the
surface of skin and to mucous membranes often rupture and bleed after slight trauma. The most common clinical manifestation is spontaneous and recurrent epistaxis beginning at approximately 12 years of age. About 25% of individuals with HHT have GI bleeding, which most commonly begins after age 40 years. Large AVMs often cause symptoms when they occur in the brain, lungs, or gastrointestinal tract, causing complications from bleeding or shunting, which may be sudden and catastrophic. The diagnosis of HHT is based on family history and the presence of cutaneous or mucocutaneous telangiectases or large visceral AVMs. HHT is caused by a mutation in ENG, the gene encoding endoglin or ACVRL1 (ALK1), the gene encoding the activin receptor. Molecular genetic testing of these genes detects mutation in 60-80% of individuals with HHT and is available on a clinical basis.
Mallory-Weiss syndrome—It is characterized by UGI bleeding secondary to longitudinal mucosal lacerations at the gastroesophageal junction or gastric cardia; may occur after any event that provokes a sudden rise in intragastric pressure or gastric prolapse into the esophagus secondary to precipitating factors such as retching or vomiting. The classic presentation consists of an episode of hematemesis following a bout of retching or vomiting. Hematemesis is present in 85% of patients. Less common presenting symptoms include melena, hematochezia, syncope, and abdominal pain. Excessive alcohol use has been reported in 40-75% of patients, and aspirin use in up to 30%.
Peutz-Jeghers syndrome—It appears to be a germline mutation of the STK11 gene, located on band 19p13.3. ; characterized by the combination of pigmented lesions in the buccal mucosa and gastrointestinal polyps. Mucocutaneous pigmen-tation and melanin spots are typical, and are present in more than 95% of cases. They appear as small, flat, brown, or dark blue spots with an
Gastrointestinal Bleeding 153
appearance of freckles, most commonly in the peribuccal area. The number, as well as the size and the location of polyps may vary from patient to patient. Isolated melanotic mucocutaneous pigmentation without gastrointestinal polyps has also been described because of the genetic variability of the syndrome. Presentation may include — repeated bouts of abdominal pain in patients younger than 25 years, unexplained intestinal bleeding in a young patient, and menstrual irregularities in females. Family history of Peutz-Jeghers syndrome may be present. Many of the gastrointestinal lesions will start developing early in life even if the syndrome is clinically apparent in the second and third decades of life. (Pigmented lesions are present in the first years of life and may fade at puberty, except for those on the buccal mucosa, making diagnosis possible in pediatric patients with a high level of suspicion). Genetic counselling and proper screening for both intestinal cancers and extraintestinal cancers should be implemented.
Solitary rectal ulcer syndrome (SRUS)—It is a rare debilitating disorder of the rectum, characterized by perianal chronic pain with passage of blood and mucus. The macroscopic appearance varies from single to multiple ulcers or even circumferential lesions. The pathogenesis remains uncertain; however, trauma to the anterior or circular rectal wall caused by straining due to functional disorders of defecation, and pelvic floor disorders are the main hypothesis. The diagnosis includes clinical symptoms associated with endoscopic lesion (erythema, ulcer or polypoid lesion). Defecography, transrectal ultrasonography, anorectal manometry, dynamic MRI, etc. are suitable procedures that may be used to detect the causative disorder. Histopathological features of SRUS are characteristic and pathognomonic; nevertheless the endoscopic
and clinical presentations may be confusing. The lesions may mimic other rectal pathologies, including primary or metastatic malignancy, and lead to wrong diagnosis.
REFERENCES
1. Thomopoulos KC, et al. Changes in aetiology and clinical outcome of acute upper gastrointestinal bleeding during the last 15 years. Eur J Gastroenterol Hepatol 2004;16(2):177-82. [PMID:
15075991: Abstract].
2. Strate LL. Lower GI bleeding: Epidemiology and diagnosis. Gastroenterol Clin North Am 2005;
34(4):643-64. [PMID: 16303575: Abstract].
3. Torres C, et al. Solitary rectal ulcer syndrome:
Clinical findings, surgical treatment, and outcomes. Int J Colorectal Dis. 2007 Nov;
22(11):1389-93. Epub 2007 Aug 14. [PMID:
17701045: Abstract].
4. Lis C, et al. Malignant tumors in the rectum simulating solitary rectal ulcer syndrome in endoscopic biopsy specimens. Am J Surg Pathol 1998;22(1):106-12. [PMID: 9422323: Abstract].
5. Al Qahtani AR, et al. Investigative modalities for massive lower gastrointestinal bleeding. World J Surg 2002 May; 26(5):620-5. Epub 2002 Mar 1.
[PMID: 12098057: Abstract].
6. Suryakanth R, et, al Obscure Gastrointestinal Bleeding – The Role of Endoscopy. MedGenMed 2006; 8(2): 38. Published online 2006 May 11.
7. Laing CJ, et al. Acute gastrointestinal bleeding:
Emerging role of multidetector CT angiography and review of current imaging techniques.
Radiographics 2007;27(4):1055-70. [PMID:
17620467: Abstract].
8. Duchesne J, et al. CT-angiography for the detection of a lower gastrointestinal bleeding source. Am Surg 2005;71(5):392-7. [PMID:
15986968: Abstract].
9. Zink SI, et al. Noninvasive evaluation of active lower gastrointestinal bleeding: Comparison between contrast-enhanced MDCT and 99m Tc-labeled RBC scintigraphy. AJR Am J Roentgenol 2008;191(4):1107-14. [PMID:
18806152: Abstract].
10. Li F, et al. Capsule endoscopy: A comprehensive review. Minerva Gastroenterol Dietol 2007;
53(3):257-72. [PMID: 17912188: Abstract].
11. Hara Amy K, et al. Imaging of Small Bowel Disease:
Comparison of Capsule Endoscopy, Standard Endoscopy, Barium Examination, and CT.
RadioGraphics 2005 25:697-711. [PMID: 15888619:
Free full text].
Diagnosis: A Symptom-based Approach in Internal Medicine 154
12. Morishima A, et al. Successful aortic valve replacement for Heyde syndrome with confirmed hematologic recovery. Ann Thorac Surg 2007;
83(1):287-8. [PMID: 17184682: Abstract].
13. Henne S.[Recurrent gastrointestinal bleeding and aortic valve stenosis (Heyde syndrome):
Need for valve replacement?] Z Gastroenterol.
2007;45(3):245-9. [PMID: 17357954: Abstract].
14. Batur P, et al. Increased prevalence of aortic stenosis in patients with arteriovenous malformations of the gastrointestinal tract in Heyde syndrome. Arch Intern Med 2003;163(15):1821-4. [PMID: 12912718:
Free full text].
15. Aljebreen AM, et al. Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding. Gastrointest Endosc 2004;59(2):172-8. [PMID: 14745388:
Abstract].
16. Witting MD. “You wanna do what?!” Modern indications for nasogastric intubation. J Emerg Med 2007;33(1):61-4. Epub 2007 May 30. [PMID:
17630077: Abstract].
17. Boley SJ, et al. On the nature and etiology of vascular ectasias of the colon. Degenerative lesions of aging. Gastroenterology 1977 Apr; 72(4 Pt 1):650-60. [PMID: 300063: Abstract].
SYNOPSIS
The term headache may be defined as any painful or nonpainful discomfort perceived more than momentarily in the cranial vault, the orbits, and the nape of the neck, i.e. from the orbits back to the suboccipital area*.
It is often difficult to explain the pain of headache. Hence it is sometimes equated to
‘invisible misery’, where quite often nothing is seen from outside and nothing is measurable on the inside.1 Some terms used by patients to explain their headache are—pressure, heaviness, tightness, throbbing, pounding, boring, bursting, or simply dull aching discomfort.
The diagnosis of headache nowadays is based on the classification criteria of The International Headache Society (IHS). The new International Classification of Headache Disorders (ICHD-II) published in January 2004 classifies headache disorders into 3 parts: part 1: primary headache, part 2: secondary headache, part 3: neuralgias and facial pain, and appendix. In total 14 different headache groups and more than 170 headache types are separated.2-4
The primary headache disorders—those not associated with an underlying pathology—include migraine, tension-type, and cluster headache.
Secondary headache disorders—those attributed to an underlying pathologic condition—include any head pain of infectious, neoplastic, vascular, drug-induced, or idiopathic origin. The vast majority of patients who present with headache have one of the primary disorders, as serious secondary causes for presentation with head pain are rare.
However, patients suffering from headaches usually fear serious brain disease, and may in fact be the harbinger of a life-threatening illness.
Further, besides the conventional CT, MRI, MRA, PET, and SPECT scans, recent imaging modalities such as functional MRI (f MRI) and voxel-based morphometry (VBM) on MRI has the potential to change our concept of primary headache disorders, requiring a radical reappraisal of the tenet of structural normality.5
In the maze of such advanced neuroimaging realities, their diagnostic outcomes, cost-effectiveness, and their constant demand for novel imaging strategies, “whether it’s nobler to scan the brain or suffer the slings and arrows of the aggrieved patient or relative, that is the clinical problem.6, 7
* Pain elsewhere in the face is not included.
Headache
23
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156
Therefore, the clinician’s prime concern while examining headache patients is, to try and distinguish the more common benign from the less common serious life-threatening causes of headache†, while maintaining a balanced approach to diagnostic testing.
DIFFERENTIAL DIAGNOSIS Common
• Systemic illness (febrile episodes: viral, typhoid, malaria)
• Migraine
• Tension headache
• Chronic daily headache
• Psychogenic (depression, anxiety)
• Vascular (subarachnoid hemorrhage, i.e.
SAH; intracerebral hemorrhage)
• CNS infections (i.e. meningitis: bacterial-Streptococcus pneumoniae, H. influenzae type b, N. meningitidis; TB; viral – HIV, HSV2, EBV;
parasitic – toxoplasma; fungal – cryptococcal‡)
• Post-traumatic headache
• Premenstrual headache
• Drug induced (nitrates; calcium channel blockers; phosphodiesterase type 5 inhibitors:
sildenafil; insulin: hypoglycemia)
• Substance abuse (alcohol, caffeine, nicotine)
• Analgesic rebound headache (analgesics, NSAIDs, ergotamine)
• Cervical spondylosis
• Referred pain (sinus, dental, aural).
Occasional
• Cluster headache
• Chronic subdural hematoma
• Accelerated/malignant hypertension
• Neoplasms (space occupying lesions, i.e. SOL)
• Ocular (acute narrow angle glaucoma, refractory errors)
• Lumbar puncture headache.
Rare
• Thunderclap headache (i.e. TCH – vide infra ↓↓).
• Giant cell arteritis (GCA)
• Benign intracranial hypertension
• Cerebral venous thrombosis
• Coital/sexual headache.8
INVESTIGATIONS—GENERAL CBC
• Rarely useful or definitive, except in a febrile patient.
ESR
• Elevated ESR (61-80 mm/hr) is useful to support the diagnosis of GCA.
Skull X-ray
• Immediately after head injury; CT scan is superior.
X-ray PNS
• Useful if sinusitis is suspected – opacification, fluid level, mucosal thickening may be visualized.
INVESTIGATIONS—SPECIFIC