Diseases » Gastrointestinal bleeding » Diagnosis

Diagnosis of Gastrointestinal bleeding

Diagnostic Test list for Gastrointestinal bleeding:

The list of medical tests mentioned in various sources as used in the diagnosis of Gastrointestinal bleeding includes:

• Stool tests
• Occult blood test
• Gastroscopy
• Endoscopy
• Nasogastric tube
• Blood tests
• ECG

Gastrointestinal bleeding Diagnosis: Book Excerpts

• Ask the Following Questions - MELENA
• Ask the Following Questions - RECTAL BLEEDING
• Ask the Following Questions - RECTAL PAIN
• Differential Diagnosis - Hemorrhoids
• Differential Diagnosis - Rectal Pain
• Differential Diagnosis - GI Bleeding - Melena & Hematochezia
• Differential Diagnosis - GI Bleeding - Hematemesis
• Differential Diagnosis - Hematochezia
• Approach to the Diagnosis - RECTAL BLEEDING
• Approach to the Diagnosis - RECTAL PAIN
• Approach to the Diagnosis - HEMATEMESIS AND MELENA
• History and physical examination - Hematochezia
• History and physical examination - Melena
• History and physical examination - Rectal pain
• History and physical examination - Vaginal bleeding, postmenopausal
• Diagnosis - Hemorrhoids
• Diagnostic tests - Introduction Gastrointestinal Disorders
• Diagnosis - Postmenopausal bleeding
• History and physical examination - Melena
• History and physical examination - Rectal pain
• History and physical examination - Hematochezia [Rectal bleeding]
• History and physical examination - Vaginal bleeding, postmenopausal
• History - Rectal Bleeding
• History - Gastrointestinal Bleeding
• History - Postmenopausal Bleeding
• Differential Overview - Rectal Pain
• Differential Overview - Gastrointestinal Bleeding
• Diagnosis - Hemorrhoids
• History - Hematochezia
• History - Melena
• History - Hematochezia
• History - Melena
• History - Rectal pain
• History - Vaginal bleeding, postmenopausal
• Clinical Features and Diagnosis - Gastrointestinal Bleeding
• History and physical examination - Melena
• History and physical examination - Rectal pain
• History and physical examination - Hematochezia [Rectal bleeding]
• History and physical examination - Vaginal bleeding, postmenopausal
• Approach to the Diagnosis - RECTAL BLEEDING
• Approach to the Diagnosis - RECTAL PAIN
• Approach to the Diagnosis - HEMATEMESIS AND MELENA
• Lower GI Bleeding - DIAGNOSIS - Lower GI Bleeding
• Upper Gastrointestinal Bleeding - DIAGNOSIS - Upper Gastrointestinal Bleeding

Tests and diagnosis discussion for Gastrointestinal bleeding:

The site of the bleeding must be located. A complete history and physical examination are essential. Symptoms such as changes in bowel habits, stool color (to black or red) and consistency, and the presence of pain or tenderness may tell the doctor which area of the GI tract is affected. Because the intake of iron or foods such as beets can give the stool the same appearance as bleeding from the digestive tract, a doctor must test the stool for blood before offering a diagnosis. A blood count will indicate whether the patient is anemic and also will give an idea of the extent of the bleeding and how chronic it may be.

Endoscopy

Endoscopy is a common diagnostic technique that allows direct viewing of the bleeding site. Because the endoscope can detect lesions and confirm the presence or absence of bleeding, doctors often choose this method to diagnose patients with acute bleeding. In many cases, the doctor can use the endoscope to treat the cause of bleeding as well.

The endoscope is a flexible instrument that can be inserted through the mouth or rectum. The instrument allows the doctor to see into the esophagus, stomach, duodenum (esophago-duodenoscopy), colon (colonoscopy), and rectum (sigmoidoscopy); to collect small samples of tissue (biopsies); to take photographs; and to stop the bleeding.

Small bowel endoscopy, or enteroscopy, is a new procedure using a long endoscope. This endoscope may be introduced during surgery to localize a source of bleeding in the small intestine.

Other Procedures

Several other methods are available to locate the source of bleeding. Barium x-rays, in general, are less accurate than endoscopy in locating bleeding sites. Some drawbacks of barium x-rays are that they may interfere with other diagnostic techniques if used for detecting acute bleeding; they expose the patient to x-rays; and they do not offer the capabilities of biopsy or treatment.

Angiography is a technique that uses dye to highlight blood vessels. This procedure is most useful in situations when the patient is acutely bleeding such that dye leaks out of the blood vessel and identifies the site of bleeding. In selected situations, angiography allows injection of medicine into arteries that may stop the bleeding.

Radionuclide scanning is a noninvasive screening technique used for locating sites of acute bleeding, especially in the lower GI tract. This technique involves injection of small amounts of radioactive material. Then, a special camera produces pictures of organs, allowing the doctor to detect a bleeding site.

In addition, barium x-rays, angiography, and radionuclide scans can be used to locate sources of chronic occult bleeding. These techniques are especially useful when the small intestine is suspected as the site of bleeding since the small intestine may not be seen easily with endoscopy. (Source: excerpt from Bleeding in the Digestive Tract: NIDDK)

Diagnostic Tests for Gastrointestinal bleeding: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Gastrointestinal bleeding.

MELENA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it true or false melena? False melena may be induced by iron ingestion, bismuth ingestion, charcoal ingestion, red wine ingestion, and many other substances.
2. Is there a history of alcohol or drug ingestion? It is surprising how often the ingestion of alcohol is overlooked. Aspirin, caffeine, anticoagulants, and reserpine are among the other drugs that may cause melena.
3. Is there associated hematemesis? The presence of hematemesis should prompt a search for esophageal varices, peptic ulcer, gastritis, and many other conditions. For a more thorough discussion of this topic, one is referred to the section on hematemesis ( page 206 ).
4. Is there abdominal pain? The presence of abdominal pain and heartburn should make one think of duodenal ulcer, esophagitis, gastritis, gastric ulcer, mesenteric embolism or thrombosis, and Meckel's diverticulum. On the other hand, the absence of abdominal pain would be more consistent with a blood dyscrasia or hereditary telangiectasia.

DIAGNOSTIC WORKUP

Routine laboratory tests include a CBC, sedimentation rate, urinalysis, chemistry panel, coagulation panel, VDRL test, and stool for occult blood. A stool for ovum and parasites may also need to be done. If these tests are inconclusive, an upper GI series and esophagogram would be the next step. Perhaps a small bowel series should be added to the above studies.

If all of these tests are negative or still inconclusive, referral to a gastroenterologist should be made. The gastroenterologist will probably perform panendoscopy and resolve the diagnostic dilemma. Occasionally, a fluorescein string test may be useful. A radioactive scan following intravenous chromium or technetium-99 may show the site of bleeding in obscure cases. When bleeding continues despite therapy, mesenteric angiography or splenic venography may assist in the diagnosis. Exploratory laparotomy may be necessary in some cases. Needless to say, a gastroenterologist should be consulted before undertaking this.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

RECTAL BLEEDING: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it severe? The presence of severe rectal bleeding would suggest ulcerative colitis, amebic dysentery, bacillary dysentery, intussusception, mesenteric thrombosis or embolism, diverticulitis, ischemic colitis, and coagulation disorders.
2. Is there diarrhea and/or mucus? The presence of diarrhea with or without mucus would suggest ulcerative colitis, amebic dysentery, or bacillary dysentery.
3. Are there signs of intestinal obstruction? The presence of signs of intestinal obstruction would suggest intussusception, mesenteric thrombosis, or embolism.
4. If the bleeding is mild, is the bleeding mixed well with the stools? Rectal bleeding that is mixed well with the stools suggests carcinoma of the colon, ulcerative colitis, Crohn's disease, Meckel's diverticulum, diverticulitis, and coagulation disorder.
5. Are there painful bowel movements? The presence of painful bowel movements, especially with bright red bleeding, would suggest anal fissure or thrombosed hemorrhoid.
6. Is there a rectal mass? The presence of a rectal mass would suggest a polyp, carcinoma, or internal hemorrhoids.

DIAGNOSTIC WORKUP

Most cases can be diagnosed by anoscopy, sigmoidoscopy, and a barium enema. A stool culture and examination for ovum and parasites should also be done. If the diagnosis is uncertain after these studies, referral to a gastroenterologist should be done for colonoscopy and other diagnostic studies. The gastroenterologist may order angiography or small intestinal enteroscopy as well as radioisotope studies.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

RECTAL PAIN: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there bleeding? The presence of bleeding with pain suggests an anal fissure, hemorrhoids, carcinoma, rectal prolapse, and intussusception.
2. Is there a mass? The presence of rectal pain along with a mass would suggest internal and external hemorrhoids, rectal carcinoma, and perirectal or ischiorectal abscesses. However, in females, masses in the cul-de-sac, such as an acute salpingitis, ectopic pregnancy, or endometriosis, will cause rectal pain. In males, prostatic abscess, foreign bodies, and seminal vesiculitis may cause rectal pain.
3. Is there a purulent discharge? Fistula in ano, perirectal abscess, ischiorectal abscess, and submucous abscess may cause a purulent discharge.

DIAGNOSTIC WORKUP

Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, VDRL test, anoscopy, sigmoidoscopy, and barium enema. In females, a pregnancy test and vaginal smear and culture should be done. Ultimately, culdocentesis, pelvic ultrasound, and laparoscopy may be necessary, but a gynecologist should be consulted before considering these tests. In males, prostatic massage may yield a urethral discharge for smear and culture. An intravenous pyelogram or cystoscopy with retrograde pyelography may also be helpful.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Hemorrhoids: Differential Diagnosis
(In a Page: Signs and Symptoms)

• External hemorrhoids
  –Located below the pectinate line
  –Typically painful
• Internal hemorrhoids
  –Located above the pectinate line
  –Typically not painful, unless thrombosis
  occurs
• Pregnancy
  –Up to 35% of pregnant females will develop hemorrhoids around the time of delivery, with most cases occurring after a vaginal delivery and/or a prolonged labor
• Condylomata acuminatum (genital warts)
• Rectal prolapse
  –External protrusion of the rectum
  –Complete prolapse versus partial full thickness prolapse versus prolapse of mucosa only
  –Partial rectal prolapse or mucosa-alone rectal prolapse is typically concentric, thus can be differentiated from internal prolapsing hemorrhoids that tend to have separation between cushions and inflammation

• Rectal polyp
• Rectal or anal cancer
• Hypertrophied anal papilla (polypoid structure at pectinate line)
• External skin tag
  –Redundant fold of tissue along the external anal margin
• Perirectal abscess
• Anal fissure or fistula
• Rectal varices
  –Develop secondary to portal hypertension
• Rectal cavernous hemangioma

Workup and Diagnosis

• History: The most common presenting complaints are bright red bleeding following defecation (in toilet or on paper), itching, and prolapse of a hemorrhoid
  –Hemorrhoids are usually not painful unless thrombosed, ulcerated, or gangrenous
  –Sudden onset of excrutiating perirectal pain with palpable mass usually suggests acute thrombosis of a hemorrhoid
• Physical exam: Evaluate for prolapse by having patient strain (may place them on a toilet to facilitate)
  –First-degree hemorrhoid: No prolapse
  –Second-degree: Prolapse during defecation followed by spontaneous return to anal canal
  –Third-degree: Prolapsed but manually reducible
  –Fourth-degree: Constant, irreducible prolapse

• Anoscopy and proctosigmoidoscopy are used to evaluate symptoms and bleeding
• Full colonoscopy is indicated in all patients over 50 years old or if diagnosis is inconclusive
• Rectal manometry is indicated if the patient complains of incontinence
• Biopsy is necessary for any rectal polyp or palpable lesion

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Source: In a Page: Signs and Symptoms, 2004

Rectal Pain: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Anal fissure
  –Acute fissure presents with pain and bleeding (noticed on toilet paper) immediately following defecation
  –Chronic fissure presents with long-standing itching and mild pain, with or without bleeding

• Perianal abscess (with or without associated fistula formation
• Thrombosed hemorrhoid
• Levator ani syndrome
• Proctalgia fugax (rectal muscle spasm)
• Coccyodynia/coccygodynia
• Fecal impaction
• Neoplasm (rectal, pelvic, or cauda equina)
• Idiopathic
• Inflammatory bowel disease (ulcerative proctitis, Crohn's disease)
• Solitary rectal ulcer syndrome
  –Misnomer: May be multiple, not restricted to rectum, and lesion may be polypoid
  –Neoplasm is a concern
• Pruritus ani
• Trauma
• Anal sex
• Constipation
• Diarrhea
• Less common causes (“zebras”) include familial rectal pain, endometriosis, pelvic inflammatory disease, prostatitis, myopathies, foreign bodies, and compression or inflammation of sacral nerves

Workup and Diagnosis

• A careful history and physical exam are crucial and often diagnostic for many conditions
  –Acute anal fissure presents as an anal tear (typically posterior) with a tender perineum; no further workup is necessary if the classic history and exam are found
  –Chronic anal fissure presents as an open ulcer with drainage and sentinel pile
  –Levator ani symptoms can be elicited by digital rectal examination
  –Proctalgia fugax symptoms cannot be elicited by exam
  –Coccyodynia: Palpation of coccyx reproduces symptoms

• In cases of perianal abscess, must rule out the presence of an anal fistula and inflammatory bowel disease
• Anoscopy may be indicated to rule out inflammatory bowel disease
• If an underlying disease process is suspected, consider stool cultures, viral titers, serologies, and/or biopsy

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Source: In a Page: Signs and Symptoms, 2004

GI Bleeding - Melena & Hematochezia: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Anatomic lesions
  –Diverticular bleeding causes 30–50% of all cases of massive rectal bleeding; associated with mild, crampy pain, but can be painless; not associated with diverticulitis
  –Meckel's diverticulum
• Vascular lesions
  –Angiodysplasia (arteriovenous malformation): Most frequent cause in older patients; bleeding tends to be episodic and self-limited; painless; increased risk with increased age
• Neoplastic lesions
  –Colon cancer or polyps: Causes 10% of cases of lower GI bleeding in patients >50 years; generally low-grade, recurrent bleeding
  –Rectal cancer
  –Small bowel tumors
• Inflammatory lesions
  –Colitis/ulcers (e.g., inflammatory bowel disease, infectious colitis, ischemic colitis, radiation colitis)
  –Ischemic colitis generally presents with abdominal pain
  –Ulcerative colitis more associated with gross rectal bleeding
  –Crohn's disease more commonly associated with diffuse crampy abdominal pain, whereas ulcerative colitis is more localized to left lower quadrant
• Anorectal lesions
  –Hemorrhoids are the most common cause of rectal bleeding in patients younger than 50 years old; usually painless bleeding
  –Fissures
  –Polyps
  –Idiopathic rectal ulcers

• Aortoenteric fistula: Must be suspected in any patient with a known aortic graft (e.g., prior aortic aneurysm repair or occlusive aortic disease)
• Idiopathic in up to 15% of cases
• Upper GI bleeding
• Systemic bleeding disorders (e.g., hemophilia, excessive anticoagulation, thrombocytopenia)

Workup and Diagnosis

• Evaluate the severity of bleeding (e.g., signs of shock, orthostatic hypotension, decreased hematocrit)—if impending shock or exsanguination, emergent resuscitation (see below) and surgical intervention are indicated
• Determine the source of bleeding
  –Rectal examination
  –Rule out upper GI bleeding by nasogastric tube aspiration or upper GI endoscopy
  –Abdominal X-ray to rule out perforation or obstruction (before initiating colonoscopy)
  –Colonoscopy is usually diagnostic for the bleeding source
  –Angiography is used for active, heavy bleeding and/or if colonoscopy is inconclusive
  –Tagged RBC scan is helpful for Meckel's diverticula
  • Initial labs should include CBC, coagulation workup (PT/PTT/INR, bleeding time, platelet count), glucose, electrolytes, BUN/creatinine, LFTs, albumin, toxicology screen (e.g., for alcohol), and stool ova/parasites culture
  • ECG may be indicated to rule out cardiac ischemia secondary to severe anemia, especially in patients with known diabetes and/or CAD

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Source: In a Page: Signs and Symptoms, 2004

GI Bleeding - Hematemesis: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Peptic ulcer disease is the most common etiology of upper GI bleeding
  –Increased risk with NSAID, steroid, or alcohol use; smoking, stress (e.g., ICU and trauma patients), or infections (Helicobacter pylori, CMV, herpes simplex virus)
• Nasopharyngeal or oropharyngeal sources of bleeding
• Esophageal etiologies
  –Esophageal varices (common in alcoholics and cirrhotic patients)
  –Erosive esophagitis: Infectious (e.g., Candida, HSV, CMV), corrosive ingestion, or pill-induced
  –Esophageal or gastric carcinoma
  –Esophageal or gastric polyps
• Gastric etiologies
  –Gastric ulcer
  –Gastritis
  –Arteriovenous malformations: Osler-Weber-Rendu syndrome (cutaneous telangectasias, recurrent nosebleeds), idiopathic angiomas, radiation-induced telangectasias, blue rubber bleb nevus syndrome
  –Mallory-Weiss tear secondary to repetitive vomiting
  –Dieulafoy's lesion: Erosion of the mucosa overlying an artery in the stomach causes necrosis of the arterial wall and resultant hemorrhage
  –Gastric varices: Secondary to splenic vein thrombosis
  –Benign or malignant tumors
• Duodenal etiologies
  –Duodenal ulcer
  –Erosion of a pancreatic tumor into the duodenum
  –Aortoenteric fistula: Must be suspected in any patient with a known aortic graft (e.g., prior AAA repair or occlusive aortic disease)
• Systemic etiologies
  –Coagulopathies (e.g., hemophilia)
  –Thrombocytopenia
  –Anticoagulation therapy (e.g., warfarin)
  –Hereditary hemorrhagic telangiectasia
  –Leukemia
  –Connective tissue disease

Workup and Diagnosis

• Evaluate the severity of bleeding (e.g., signs of shock, orthostatic hypotension, decreased hematocrit) and begin immediate resuscitation if necessary

• Identify the source of bleeding
  –Nasogastric tube insertion to verify upper GI bleeding
  –Upper GI endoscopy (EGD) is diagnostic in most cases (identifies the source of bleeding in 90% of patients) and may be therapeutic
  –Angiography (radionuclide or conventional) is indicated for severe bleeds, if endoscopy is not available, or if endoscopy is inconclusive
  –If patient has a known aortic graft (prior aneurysm repair or aortic occlusive disease), a high index of suspicion for an aortoenteric fistula
• Initial labs should include CBC, coagulation workup (PT/PTT/INR, bleeding time, platelet count), glucose, electrolytes, BUN/creatinine, calcium, liver function tests, and toxicology screen (e.g., for alcohol)
  –Elevated BUN/creatinine ratio suggests upper GI bleed
  –Abnormal prothrombin time suggests coagulopathy
  –Serial hemoglobin/hematocrit measurements are necessary as they may be initially high until volume is replaced; then may decrease

• ECG may be indicated to rule out cardiac ischemia secondary to severe anemia, especially in patients with known diabetes and/or coronary heart disease

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Source: In a Page: Signs and Symptoms, 2004

Hematochezia: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Milk or soy protein allergy (colitis)
• Anorectal fissure: passage of hard stool causing rectal trauma
• Nectrotizing enterocolitis (NEC): Vast majority occur in premature infants

• Infectious colitis
  –Bacterial: Salmonella, Shigella, Campylobacter, Yersinia, Clostridium difficile, and E. coli (O157:H7) –Parasitic: Entamoeba histolytica

• Immunocompromised host
  –CMV enterocolitis
  –Disseminated aspergillosis
  –Mycobacterium avium complex
  –Typhlitis: Polymicrobial inflammation of the cecum associated with neutropenia
• AIDS
  –Aphthous ulcerations of the intestine
• Juvenile polyps
  –Most common source of significant rectal bleeding in childhood
  –Pathologically benign inflammatory polyps
• Inflammatory bowel disease
• Meckel diverticulum: Ectopic gastric mucosa, 2% of population
• Intestinal duplication
• Henoch-Schönlein purpura (HSP)
• Lymphonodular hyperplasia
• Solitary rectal ulcer
• Ischemic injury
  –Malrotation with volvulus
  –Intussusception
  –Postoperative (colonic watershed regions)
  –Acute drug-induced ischemia (cocaine)
• Hirschprung enterocolitis
• Foreign body injury: Ingested glass, broken glass thermometer, other sharp objects
• Munchausen syndrome by proxy
• Vascular lesions
  –Hemangiomas (rare)
  –Arteriovenous, venous malformation
  –Klippel-Trenaunay syndrome
  –Blue rubber bleb nevus syndrome
  –Hereditary hemorrhagic telangiectasia
• Hemorrhoids and colorectal varices from portal hypertension
  –Hemorrhoids rarely bleed in children

Workup and Diagnosis

• History and physical exam
  –Painless rectal bleeding is typical of juvenile polyp, vascular lesions, Meckel, or ulcerated duplication
  –Crampy abdominal pain, bloody/mucoid stool, with or without fever suggest infectious, inflammatory, or ischemic process in the colon
  –History of constipation and blood streaked stool points toward anorectal fissure
  –Skin examination for vascular lesions
  –Anal inspection and rectal examination may reveal markers of IBD, such as a skin tag, fistula, or fissures

• Stool examination: Currant-jelly stool is a late sign in intussuception; maroon-colored stool may represent blood from a distal small bowel lesion (e.g., Meckel); bacterial culture, C. difficile toxin assay, O&P
• CBC, blood smear, urinalysis, BUN, and Cr to evaluate for HUS
• Endoscopy
  –Colonoscopy is the most valuable tool after infections have been ruled out
  –May offer both diagnosis and therapy (polypectomy)
• X-rays: Obstructive series useful when pain or vomiting is present; thumb printing seen with bowel wall edema; pneumoperitoneum with perforation
• Ultrasound: Can detect intussuception
• Meckel scan (Tc-petichnitate)
• Angiography, scintigraphy, push enteroscopy, or capsule endoscopy for vascular lesions

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Source: In A Page: Pediatric Signs and Symptoms, 2007

RECTAL BLEEDING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Armed with a more comprehensive list of causes of rectal bleeding, the clinician is ready to eliminate some of them as he or she asks appropriate questions during the history and performs the examination with all the causes in mind. The diagnosis may be pinned down by the presence or absence of other symptoms and signs. The principal diagnostic procedures are stool cultures, stool examination for ova and parasites, proctoscopy, barium enema, and colonoscopy.

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Source: Differential Diagnosis in Primary Care, 2007

RECTAL PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The cause of rectal pain is usually obvious on examination with an anoscope or proctoscope. Careful palpation may be necessary to discover a perirectal abscess, coccydynia, or an ectopic pregnancy. Anal fissures may be missed unless all quadrants of the anus are examined with the slitanoscope.

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Source: Differential Diagnosis in Primary Care, 2007

HEMATEMESIS AND MELENA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

When confronted with solid evidence of hematemesis, the clinician should not waste valuable time on a thorough history and physical examination when endoscopy is more important in both diagnosis and therapy. Ordering a type and cross for multiple units of blood, coagulation studies, and the other tests listed below should also be done immediately in most cases. The history of alcoholism, use of aspirin and other drugs, and previous ulcers or esophageal disease is important to get while preparing for endoscopy and other emergency procedures. Patients without massive or recent acute hematemesis may be approached with traditional methods. A history of vomiting nonhemorrhagic gastric fluid before the onset of hematemesis is helpful in diagnosing a Mallory–Weiss syndrome.

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Source: Differential Diagnosis in Primary Care, 2007

Hematochezia: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If hematochezia isn’t immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.

Next, explore the patient’s medical history, focusing on GI and coagulation disorders. Ask about the use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs (NSAIDs).

Begin the physical examination by checking for orthostatic hypotension, an early sign of shock. Take the patient’s blood pressure and pulse while he’s lying down, sitting, and standing. If systolic pressure decreases by 10 mm Hg or more or if the pulse rate increases by 10 beats/minute or more when he changes position, suspect volume depletion and impending shock.

Examine the skin for petechiae or spider angiomas. Palpate the abdomen for tenderness, pain, or masses. Also, note lymphadenopathy. Finally, a digital rectal examination must be done to rule out rectal masses or hemorrhoids.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Melena: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient’s condition permits, ask when he discovered his stools were black and tarry. Ask about the frequency and quantity of bowel movements. Has he had melena before? Ask about other signs and symptoms, notably hematemesis or hematochezia, and about use of anti-inflammatories, alcohol, or other GI irritants. Also, find out if he has a history of GI lesions. Ask if the patient takes iron supplements, which may also cause black stools. Obtain a drug history, noting the use of warfarin or other anticoagulants.

Next, inspect the patient’s mouth and nasopharynx for evidence of bleeding. Perform an abdominal examination that includes auscultation, palpation, and percussion.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Rectal pain: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient reports rectal pain, inspect the area for bleeding; abnormal drainage, such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.

After the examination, proceed with your evaluation by taking the patient’s history. Ask him to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

Make sure to ask appropriate questions about the development of associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Vaginal bleeding, postmenopausal: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her periods regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.

Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Hemorrhoids: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Physical examination confirms external hemorrhoids. Proctoscopy confirms internal hemorrhoids and rules out rectal polyps.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Introduction: Gastrointestinal Disorders: Diagnostic tests
(Professional Guide to Diseases (Eighth Edition))

After physical assessment, several tests can identify GI malfunction.

❑ A barium or gastrografin swallow is used primarily to examine the esophagus. Gastrografin may be used instead of barium. Like barium, gastrografin facilitates X-ray imaging. However, if gastrografin escapes from the GI tract, it’s absorbed by the surrounding tissue, whereas escaped barium isn’t absorbed and can cause complications.

❑ In an upper GI series, swallowed barium sulfate travels through the esophagus, stomach, and duodenum to reveal abnormalities. The barium outlines stomach walls and delineates ulcer craters and defects.

❑ A small-bowel series, an extension of the upper GI series, visualizes barium flowing through the small intestine to the ileocecal valve.

❑ A barium enema (lower GI series) allows X-ray visualization of the colon.

❑ A stool specimen is useful to detect suspected GI bleeding, infection, or malabsorption as well as the presence of parasites. Guaiac test for occult blood, microscopic stool examination for ova and parasites, and tests for fat require several specimens.

❑ In esophagogastroduodenoscopy, insertion of a fiber-optic scope allows direct visual inspection of the esophagus, stomach, and duodenum. These structures are examined for varices, tumors, inflammation, hernias, polyps, ulcers, and obstruction.

❑ Proctosigmoidoscopy permits inspection of the rectum and distal sigmoid colon; colonoscopy is used for inspection of the descending, transverse, and ascending colon. These tests help visualize tumors, polyps, hemorrhoids, or ulcers.

❑ Gastric analysis examines gastric secretions for the presence of high levels of gastrin and the amount of acid produced.

❑ Endoscopic retrograde cholangiopancreatography directly visualizes the esophagus, stomach, proximal duodenum, and fluoroscopic visualization of the pancreatic, hepatic, and biliary ducts. This test can help visualize duct obstruction, benign structures, cysts, anatomic variations, and malignant tumors.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Postmenopausal bleeding: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnostic evaluation of the patient with postmenopausal bleeding should include physical examination (especially pelvic examination), a detailed history, standard laboratory tests (such as complete blood count), and cytologic examination of smears from the cervix and the endocervical canal. An endometrial biopsy or dilatation and curettage (D & C) with hysteroscopy reveals pathologic findings in the endometrium.

Diagnosis must rule out underlying degenerative or systemic disease. For instance, evidence of elevated levels of endogenous estrogen may suggest an ovarian tumor. Before testing for estrogen levels, the patient must stop all sources of exogenous estrogen intake — including face and body creams that contain estrogen — to rule out excessive exogenous estrogen as a cause.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Melena: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s condition permits, ask when he discovered his stools were black and tarry. Ask about the frequency and quantity of bowel movements. Has he had melena before? Ask about other signs and symptoms, notably hematemesis or hematochezia, and about use of anti-inflammatories, alcohol, or other GI irritants. Also, find out if he has a history of GI lesions. Ask if the patient takes iron supplements, which may also cause black stools. Obtain a drug history, noting the use of warfarin or other anticoagulants.

Next, inspect the patient’s mouth and nasopharynx for evidence of bleeding. Perform an abdominal examination that includes auscultation, palpation, and percussion.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Rectal pain: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If your patient reports rectal pain, inspect the area for bleeding; abnormal drainage such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Check for inflammation and other lesions. A rectal examination may be necessary.

After examination, proceed with your evaluation by taking the patient’s history. Ask the patient to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

Be sure to ask appropriate questions about the development of any associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Hematochezia [Rectal bleeding]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the hematochezia isn’t immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.

Next, explore the patient’s medical history, focusing on GI and coagulation disorders. Ask about the use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs.

Begin the physical examination by checking for orthostatic hypotension, an early sign of shock. Take the patient’s blood pressure and pulse while he’s lying down, sitting, and standing. If systolic pressure decreases by 10 mm Hg or more, or pulse rate increases by 10 beats/minute or more when he changes position, suspect volume depletion and impending shock.

Examine the skin for petechiae or spider angiomas. Palpate the abdomen for tenderness, pain, or masses. Also, note lymphadenopathy. Finally, a digital rectal examination must be done to rule out rectal masses or hemorrhoids.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Vaginal bleeding, postmenopausal: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her periods regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.

Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Rectal Bleeding: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Initial history. The history is an important tool for risk stratification. Important questions to ask: What is the color of blood passed? Is the bowel movement associated with pain? How long has the bleeding occurred? Is there blood on toilet tissue versus mixed with stool, or dripping into the toilet bowel? Have there been prior episodes? Is abdominal pain, constipation, diarrhea, medication use, or weight loss present? What medications do you take? The only historical questions that have evidence-based data to support benign versus serious pathology are the presence of constipation, diarrhea, age less than 50 years, and bleeding longer than 2 months (1,2) (Chapters 9.3 and 9.4). These findings are associated with more benign causes. An exception to this is in the pediatric age group where bleeding in children can represent hereditary and anatomic anomalies (4).

B. Other questions that can help discriminate serious from benign causes are a change in bowel habit to persistent loose stools for more than 1 month, absence of perianal symptoms in the presence of rectal bleedings, first time rectal bleeding, and the appearance of dark red blood (3). These are especially likely to be associated with more serious causes.

Physical examination

 Assess the patient’s weight, general condition, and vital signs. Orthostatic blood pressure changes with a drop of 10 mm Hg or an increase in heart rate of 10 beats/minute indicates a blood loss of at least 1,000 ml (20% of circulating blood volume) (5). It is important to perform an external anal inspection, (checking for external hemorrhoids, fissures), digital rectal examination (checking for a rectal mass, polyp or anal pain), abdominal examination (checking for tenderness or mass), and nasopharyngeal examination (checking for a bleeding source).

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Gastrointestinal Bleeding: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Clinical history accurately points to the source of bleeding in only 40% of cases (3).

 A. Upper GI bleeding. Hematemesis and melena are the most common presentations of acute upper GI bleeding. Important questions to ask: Is there a prior history of bleeding (60% rebleed from the same site) (3)? Is there any family history? Does the patient have any comorbid diseases (peptic ulcer disease, pancreatitis, cirrhosis, cancer)? Is the patient taking any medications (especially nonsteroidal antiinflammatory agents)? Does the patient use recreational drugs, cigarettes, or alcohol? What is the character of the pain? Peptic ulcer pain is epigastric, gnawing, rhythmic, and dull. GI cancers are associated with vague epigastric pain, dysphagia, or weight loss. Was there any retching (Mallory–Weiss tear)? Does the patient have a history of prior surgeries? Patients with a history of vascular grafting are at risk for aortoenteric fistulae, which is often associated with a “herald bleed.”

 B. Lower GI bleeding. How old is the patient? Age is an important feature in discriminating the source of lower GI bleeding. Patients aged less than 50 years usually bleed from infectious causes, anorectal disease, or inflammatory bowel disease. For patients aged more than 50 years, diverticulosis, angiodysplasia, cancer, and ischemia are most common (4). Are there any associated symptoms? Diverticular disease presents as painless, high volume bleeding. Angiodysplasia and cancer present with symptoms of chronic blood loss (fatigue, dyspnea on exertion). Inflammatory bowel disease presents with bloody diarrhea, cramping, weight loss, and fever. A prior history of inflammatory bowel disease, cancer, or radiation to the abdomen is also important.

Physical examination

A. Vital signs. The single most important aspect of the initial physical examination is determining the patient’s hemodynamic stability. Unstable patients should be managed as trauma patients. Placement of a nasogastric (NG) tube is considered the “fifth vital sign” in patients with acute GI bleeding (2).

 B. Focused physical examination. After ensuring hemodynamic stability, the initial physical examination should eliminate a nasal or oropharyngeal source of bleeding. Examine the skin and abdomen carefully for clues to an underlying cause. A rectal examination is mandatory.

1. Skin examination. Ecchymoses, petechiae, and varices should be noted. Conjunctival pallor is a sign of chronic anemia. Numerous mucosal telangiectasias can point to an underlying vascular abnormality.

 2. Abdominal examination. Look for stigmata of chronic liver disease (hepatosplenomegaly, spider angiomata, ascites, palmar erythema, caput medusae, gynecomastia, and testicular atrophy) (Chapter 9.9).

 3. Rectal examination. Rectal varices, hemorrhoids, and fissures should be noted.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Postmenopausal Bleeding: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Pattern of bleeding. Although the amount of bleeding is not helpful in identifying malignancy, it should be assessed to determine the likelihood of significant anemia or hypovolemia that may require intervention. Timing of bleeding may suggest its cause.

 1. Specific relationship to medication courses or cycles suggests drug-induced bleeding.

 2. Postcoital bleeding suggests an atrophic cause or cervical polyp.

 3. Association with bowel movements or urination suggests a nongenital source.

 B. Current medications. Any hormonal therapy, including estrogen, progesterone, tamoxifen, thyroid replacement, or corticosteroids, should be quantified and recorded.

 1. Acyclic bleeding is common in the first 3 to 4 months on continuous estrogen–progestin therapy, and usually does not indicate pathology. Bleeding that is excessive, persists after months of therapy, or occurs after amenorrhea has been established on these regimens should be evaluated.

2. The rate of endometrial cancer in women on tamoxifen or unopposed estrogen is six to seven times the rate for untreated women. The frequency of endometrial polyps is also increased.

3. Exogenous corticosteroids and incorrect dosage of thyroid replacement can lead to menstrual irregularities and postmenopausal bleeding.

C. Past medical history. Nulliparity, early menarche, late menopause, and history of chronic anovulation are risk factors for endometrial hyperplasia and carcinoma. Obesity, hypertension, diabetes, and liver disease are commonly associated with estrogen excess, and can also increase risk (1). Past use of oral contraceptives is associated with decreased risk.

D. Family history. A strong family history of endometrial or colon cancer is a risk factor for endometrial cancer.

Physical examination

A. Vital signs. Blood pressure and pulse can indicate the degree and acuity of blood loss; orthostatic changes can be evidence of significant volume depletion. Fever suggests infection as a potential cause (Chapter 2.6).

B. Abdomen. Tenderness or guarding suggests an infectious or inflammatory cause. Palpation for suprapubic masses is necessary as part of the evaluation for malignant causes.

C. Pelvis. Examine external genitalia, vagina, and cervix for lesions or lacerations that could be the source of bleeding. The uterus and ovaries must be palpated to assess for enlargement, masses, and tenderness.

D. Rectum. Rectal examination and anoscopy may be warranted to rule out hemorrhoids or other intestinal source of bleeding (Chapter 9.11).

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Rectal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Hemorrhoid

❑ Rectal fissure

❑ Prostatitis

❑ Anal fistula

❑ Pruritus ani

❑ Fecal impaction

❑ Coccydynia

❑ Perirectal abscess

❑ Infected pilonidal cyst

❑ Ulcerative proctitis

❑ Infective proctitis

❑ Proctalgia fugax

❑ Anal carcinoma

Diagnostic Approach

Tenesmus is a painful urge to defecate with little result.

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Source: Field Guide to Bedside Diagnosis, 2007

Gastrointestinal Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

Upper GI

❑ Peptic ulcer disease

❑ Gastritis

❑ Mallory-Weiss tear

❑ Esophageal varices

❑ Esophagitis

❑ Epistaxis

❑ Esophageal cancer

❑ Gastric cancer

Lower GI

❑ Infectious diarrhea

❑ Diverticular bleeding

❑ Hemorrhoids

❑ Anal fissure

❑ Inflammatory bowel disease

❑ Angiodysplasia

❑ Colon cancer

❑ Mesenteric ischemia

❑ Aortoenteric fistula

DIagnostic Approach

With overt bleeding, determining whether a source is proximal or distal to the ligament of Treitz is key to the further diagnostic evaluation. Hematemesis confirms an upper GI source, and suggests loss of more than a quarter of blood volume. Melena (black, tarry stool) also comes from an upper source unless the bleeding is brisk or large volume and transit is rapid. Melena without hematemesis usually results from a lesion distal to the pylorus (e.g., duodenal ulcer) or to slow bleeding. Tarry stools may be produced by as little as 100 mL of blood. Lower sources produce hematochezia (maroon or clots from the right colon and bright red from the left colon). A small amount of blood only on the toilet tissue nearly always comes from a bleeding hemorrhoid or fissure. Silver stool is said to arise from acholic stools combined with luminal bleeding in an ampullary cancer.

Determine the hemodynamic significance of the bleeding by looking for postural lightheadedness or changes in pulse or blood pressure. Early symptoms of thirst and lightheadedness occur with loss of more than 15% of intravascular volume. An orthostatic blood pressure drop of 10 mm Hg indicates a loss greater than or equal to 20% of volume. Shock with hypotension and pallor develops with 25% to 40% volume loss.

Stools may be falsely colored by ingestants such as bismuth subsalicylate, iron, licorice or charcoal, which turn it black, or beets, which turn it red. These stools are not sticky. A negative stool test for occult blood will usually resolve this.

Hemoccult screening detects blood loss down to 1 to 10 ml/day. Evaluation of a heme positive stool will reveal colon cancer in 5% to 14% of patients, and large adenomatous polyps in another 15% to 35%. Any single positive stool should be evaluated. Hemoccult screening reduces colon cancer mortality by 15% to 33%. An asymptomatic patient with a negative Hemoccult has only a 0.2% chance of having colon cancer (compared with 1.4% prevalence in this population). Using Hemoccult alone as a screening strategy will miss 50% to 60% of colon cancers.

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Source: Field Guide to Bedside Diagnosis, 2007

Hemorrhoids: Diagnosis
(Handbook of Diseases)

Physical examination confirms external hemorrhoids. Anoscopy or proctoscopy provides for visual examination of internal hemorrhoids.

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Source: Handbook of Diseases, 2003

Hematochezia: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the hematochezia isn’t immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of the bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.

Next, explore the patient’s medical history, focusing on GI and coagulation disorders. Ask about use of GI irritants, such as alcohol, aspirin, and other NSAIDs.

Physical examination

Begin the physical examination by checking for orthostatic hypotension, an early sign of shock. Take the patient’s blood pressure and pulse while he’s lying down, sitting, and standing. If systolic pressure decreases by 10 mm Hg or more, or pulse rate increases by 10 beats/minute or more when he changes position, suspect volume depletion and impending shock.

Examine the skin for petechiae or spider angiomas. Palpate the abdomen for tenderness, pain, or masses. Also, note lymphadenopathy. Finally, a digital rectal examination must be done to rule out any rectal masses or hemorrhoids.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Melena: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient’s condition permits, ask when he discovered his stools were black and tarry. Ask about the frequency and quantity of bowel movements. Has he had melena before? Ask about other signs and symptoms, notably hematemesis or hematochezia, and about use of anti-inflammatories, alcohol, or other GI irritants. Also, find out if he has a history of GI lesions. Ask if the patient takes iron supplements, which may also cause black stools; also ask if the patient has ingested black licorice, lead, Pepto-Bismol, or blueberries. Obtain a drug history, noting the use of warfarin or other anticoagulants.

Physical examination

Next, inspect the patient’s mouth and nasopharynx for evidence of bleeding. Perform an abdominal examination that includes auscultation, palpation, and percussion. Perform a cardiovascular assessment to detect signs and symptoms of shock.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Hematochezia: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the hematochezia isn’t immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.

Explore the patient’s medical history, focusing on GI and coagulation disorders. Ask about use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs.

CULTURAL CUE:In the Chinese culture, discomfort isn’t usually displayed openly. Direct questioning and vigilant assessment skills are necessary to ensure that a Chinese patient’s quiet nature doesn’t mask signs and symptoms that may be life-threatening.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Melena: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s condition permits, ask when he discovered his stools were black and tarry. Ask about the frequency and quantity of bowel movements. Has he had melena before? Ask about other signs and symptoms, notably hematemesis or hematochezia, and about use of anti-inflammatories, alcohol, or other GI irritants. Also, find out if he has a history of GI lesions. Ask if the patient takes iron supplements, which may also cause black stools. Obtain a drug history, noting the use of warfarin or other anticoagulants.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Rectal pain: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

Be sure to ask appropriate questions about the development of any associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Vaginal bleeding, postmenopausal: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her menses regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Gastrointestinal Bleeding: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Upper Gastrointestinal Bleeding

Nose

See Chap.18, Epistaxis.

Mouth and Pharynx

Trauma orforeign body may produce bleeding in mouth or pharynx.

History and physical exam are usuallydiagnostic.

Esophagus

Esophagitis

May presentwith hematemesis and sometimes occult blood loss.

Gastroesophageal reflux and causticingestions are common causes. Less common cause is infection, whichusually occurs in immunocompromised individuals. Pathogens includeherpes simplex virus, adenoviruses, cytomegalovirus, VZV, and Candidaspecies.

Diagnosis of esophagitis may be confirmedby endoscopy and biopsy. These infections may be diagnosed by specificcultures.

Foreign Body

Foreignbody lodged in esophagus may cause difficulty swallowing, pain,and bleeding.

Chest radiography may show radiopaqueforeign body.

Endoscopy is definitive procedure forremoval.

Varices

Consequenceof portal hypertension.

Major causes of portal hypertensionare parenchymal liver disease and anatomic obstruction of portalvein or its major branches.

Acute painless GI bleeding that occasionallycan be massive is often presenting sign. Other findings may includevisible abdominal wall collateral vessels, splenomegaly, and ascites.Hepatomegaly usually indicates liver parenchymal disease, but acirrhotic liver may be small and shrunken.

Endoscopic exam visualizes varices.

Duplication

Usuallyinvolves lower esophagus and may cause dysphagia.

Large duplication also may cause respiratorydistress.

If duplication contains ectopic gastricmucosa, bleeding can occur.

Diagnosis can usually be made by chestCT with oral contrast.

Gastroesophageal Junction

Tears inmucosa at gastroesophageal junction can result from continued forceful vomitingand retching; condition is called Mallory-Weiss syndrome.

Bleeding is usually self-limited.

Endoscopy can confirm diagnosis.

Stomach

Gastritis

In neonates,gastritis may be due to perinatal asphyxia, septicemia, or hypotension, butoften it is unexplained.

In infancy and childhood, epigastricpain and vomiting are frequent findings with gastritis. Viral illnessand drugs (e.g., aspirin and NSAIDs) are predisposing factors.

In adolescence, chronic alcohol intakemay cause gastritis.

In any age group, causes of stressgastritis include head injury, burns, septicemia, and shock.

Gastric aspirate may contain materialresembling coffee grounds or bright red blood.

Ulcer

Gastriculcer may cause acute bleeding with hematemesis or melena.

Another presentation is finding bloodin stool associated with chronic blood loss and anemia.

See Chap.2, Abdominal Pain.

Duplication

Duplicationof stomach usually involves greater curvature near antrum or pylorus.

Neonates may have vomiting, abdominalmass, and abdominal distension.

Vomiting, intermittent abdominal pain,and GI bleeding may occur in childhood.

Abdominal U/S is usually diagnostic.

Vascular Malformation

Angiodysplasticlesions and arteriovenous malformations can occur in stomach and insmall and large intestine.

Any of these lesions can present withrecurrent painless upper or lower GI tract bleeding.

Endoscopy and angiography are bestavailable diagnostic tools.

Neoplasm

Gastricneoplasms are extremely rare in pediatric population, yet can causeGI bleeding.

Benign tumors include teratoma andleiomyoma, whereas malignant tumors include gastric carcinoma, lymphoma,and leiomyosarcoma.

Combination of abdominal U/S,CT, and endoscopy with biopsy are diagnostic.

Duodenum

In addition to conditions detailed below,varices and vascular malformations can cause GI bleeding.

Ulcer

Duodenalulcer can have similar presentation as gastric ulcer.

See Chap.2, Abdominal Pain.

Foreign Body

Occasionallysharp objects may pass from stomach into duodenum and cause bleeding.Swallowed foreign body may be held up in C loop of duodenum or atpoint of constriction (e.g., ligament of Treitz) and cause obstructivesymptoms and hematemesis.

Combination of plain abdominal radiography,abdominal U/S, and endoscopy is usually diagnostic.

Duplication

Tends tocompress first or second portions of duodenum, producing partialobstruction. Presence of ectopic gastric mucosa predisposes to GIbleeding.

Abdominal U/S is usually diagnostic.

Hemobilia

Most commoncause of bleeding into biliary tract in children is abdominal trauma withinjury to liver and biliary tree.

Abdominal U/S and CT are usefulin locating and defining extent of injury. Duodenal endoscopy mayshow blood oozing from ampulla. If this is negative, celiac angiographymay locate site of bleeding if brisk. If bleeding is slower, technetium-sulfurcolloid scan may detect bleeding.

Other

Swallowed Blood

Maternalblood can be swallowed during passage through birth canal or frombreast-feeding if nipples are cracked.

Apt test can determine whether RBCsare fetal or maternal in origin and can be performed on either NGaspirate or stool.

In this test, small amount of NG contents orstool is mixed with tap water (1 part stool:5 parts water).

After centrifugation, 1 mL of 0.25NNaOH is added to 5 mL of pink supernatant fluid; mixture is leftfor 5 mins.

Pink color signifies fetal Hgb, whereasbrownish yellow color signifies maternal Hgb.

Coagulopathy

Bruising,purpura, and bleeding from sites other than GI tract are clues topresence of systemic bleeding disorder.

See Chap.52, Purpura and Bleeding.

Hemorrhagic Disease of the Newborn (Vitamin K Deficiency)

Becauseneonates have low vitamin K stores, they often fail to develop effectivecoagulation function.

At 2–4 days of age, if vitaminK has not been given at birth, hematochezia, melena, or hematemesismay develop. Bleeding also may occur from other sites beside GItract.

Lack of vitamin K administration atbirth, normal platelet count, and reversal of prolonged prothrombintime (PT) and activated partial thromboplastin time (aPTT) withdecreased bleeding after vitamin K administration confirm diagnosis.

Every newborn should receive 0.5–1.0mg IM of vitamin K at birth so this problem can be prevented.

Disseminated Intravascular Coagulation

Predisposingcauses include bacterial meningitis, septicemia, severe hypoxia,necrotizing enterocolitis, and shock.

Patients are seriously ill and havediffuse bleeding from multiple sites from consumption of clottingfactors and destruction of platelets.

Certain lab findings help confirm diagnosis:low platelet count, fragmented RBCs on blood smear, prolonged PTand aPTT, low plasma fibrinogen, and increase in fibrin-split products.

Drugs

GI bleeding may occur with chronic ingestionof aspirin, which causes a defect in platelet aggregation and aprolonged bleeding time. Excessive use of NSAIDs and anticoagulantsalso may cause significant GI bleeding.

Lower Gastrointestinal Tract Bleeding

Intestine

Cow Milk/Soy Protein Sensitivity

Infantsoften present with diarrhea that contains blood. Practical way tomanage this problem is to eliminate cow milk or soy protein fromdiet and monitor for whether symptoms disappear.

See Chap.14, Diarrhea.

Necrotizing Enterocolitis

Common disorderin preterm infants that can occur in term infants. History of perinatalstress (asphyxia, hypotension, septicemia) often exists.

Clinical findings include poor feeding,lethargy, abdominal distension, bilious vomiting, and bloody orblood-streaked stools.

Abdominal radiography that shows gasin bowel wall or in portal venous system helps confirm diagnosis.

Infectious Colitis

Most frequentpathogens in infancy and childhood are Salmonella, Shigella, Campylobacter,and E. coli. Less common is infection with C. difficile and Y. enterocolitica.Most common pathogen associated with HUS is E. coli 0157:H7.

Usual presenting manifestations arefever and bloody diarrhea.

Positive stool culture is diagnostic,except for infection with C. difficile, for which toxin must beidentified.

Henoch-Schönlein Purpura

Lower GIbleeding from the small intestine or colon can be occult or obvious.Typical purpuric rash occurs on buttocks and lower legs.

See Chap.28, Hematuria.

Intussusception

Common causeof lower GI bleeding in children 2 mos–5 yrs of age.

Most common type is ileocolic, whichinvolves telescoping of distal ileum into ascending or transversecolon.

History of intermittent cramping abdominalpain is usually presenting symptom. Vomiting and bloody (currantjelly) stools also may occur. Abdominal mass may be palpable anywherein abdomen.

Abdominal radiography that shows leadingedge of intussusceptum outlined by air is diagnostic, but oftenradiographs are nonspecific. Air-contrast enema can be diagnosticas well as therapeutic. Contraindications to its use are free abdominalair, intestinal obstruction with fluid levels on abdominal radiography,and clinical peritonitis. With any of these findings, surgery shouldbe performed immediately.

Congenital Aganglionic Megacolon (Hirschsprung Disease)

Enterocolitismay occur as complication.

Most common manifestations are abdominaldistension, diarrhea that is often bloody, fever, and vomiting.

See Chap.9, Constipation, and Chap. 14, Diarrhea.

Meckel Diverticulum

Remnantof omphalomesenteric duct that is located in distal ileum.

Usually presents in infancy with painless,episodic, bright red rectal bleeding, which may be massive.

Most diverticula contain gastric mucosa,and technetium 99m–pertechnetate scan can be diagnostic.

False-positive scans are uncommon butsometimes occur with ulcer, hemangioma, or bowel duplication.

Laparoscopy or laparotomy may sometimesbe necessary to confirm diagnosis.

Volvulus with Malrotation

Usuallypresents with intestinal obstruction; however, lower GI bleedingalso can occur.

Abdominal radiography shows dilatedloops of bowel with air-fluid levels. Upper GI series is usuallyperformed; however, with suspected bowel infarction, contrast studiesare unnecessary, and surgery should be performed immediately.

Inflammatory Bowel Disease

Occult GIblood loss or obvious lower GI tract bleeding may occur. Chronicdiarrhea with lower GI bleeding and weight loss should suggest IBD.

Crohn disease and ulcerative colitisare types of IBD.

See Chap.14, Diarrhea.

Intestinal Polyps

Definedas protrusion of tissue above normal GI surface that can cause bleedingand occasionally intussusception.

Number and location of polyps, theirhistopathology, and family history of colorectal cancer helps determineproper management.

This section focuses on common polyposissyndromes in pediatric population.

Solitary Juvenile Polyps/Juvenile Intestinal Polyposis

Solitaryjuvenile polyps usually present with painless rectal bleeding oranal prolapse of polyp in children 2–10 yrs of age. Mostchildren have single polyp, which should be removed for histopathologicexam.

Children with ≥2 rectosigmoid polypsand family history of polyps should be suspected of having juvenileintestinal polyposis, which is transmitted as autosomal-dominanttrait.

Manypolyps occur in the colon, but they also may be found in small intestineand stomach.

Age of presentation is usually in school-agedchildren.

Clinical manifestations include abdominalpain, rectal bleeding, and anemia.

There is high incidence of colorectalneoplasia in individuals with this disorder.

Adenomatous Polyposis of Colon

Autosomal-dominantdisorder caused by mutations in adenomatous polyposis coli gene,whose locus has been mapped to chromosome 5q21-q22.

Characterized by premalignant adenomaslocated primarily in colon and rectum and less commonly in stomachand small intestine.

Onset is usually in adolescence, whenhundreds to thousands of adenomas may appear. Other manifestationsinclude osteomas (jaw, long bones), skin lesions (cysts, lipomas),and pigmented retinal lesions.

Diagnosis is confirmed by colonoscopyand biopsy.

Peutz-Jeghers Syndrome

Autosomal-dominantdisorder in which hamartomatous polyps occur primarily in smallintestine but also may be found in colon and stomach. Gene locushas been mapped to chromosome 19p13.3.

Besides GI bleeding, characteristicfeature is presence of hyperpigmentation, which is seen most commonlyon buccal mucosa and lips.

Upper and lower GI endoscopy and upperGI radiographic series should be performed.

These individuals are at increasedrisk for adenocarcinoma, especially of stomach, duodenum, and colon.

Benign Lymphoid Hyperplasia

Large aggregatesof lymphoid tissue occur in colon and rectum. Rectal bleeding and sometimesintermittent diarrhea occur.

Proctosigmoidoscopy, colonoscopy, andhistologic exam confirm diagnosis.

Duplication

May be foundin jejunum and ileum. Abdominal pain, partial intestinal obstruction, orGI bleeding can be presenting feature. Sometimes small bowel intussusceptionor volvulus occurs.

May also involve colon and rectum,but bleeding rarely occurs because colonic duplications rarely containgastric mucosa. Affected individuals may present with abdominalpain and partial intestinal obstruction or they may be asymptomatic.

Abdominal U/S is usually diagnostic,although abdominal CT may be useful in some cases.

Vascular Malformation

Althoughrare, angiodysplastic lesions and arteriovenous malformations cancause lower GI bleeding.

Diagnosis is usually made by angiography.

Neoplasm

GI tumorsare rare in children.

Hemangiomas can be found anywhere insmall or large intestine but usually involve sigmoid colon and rectum.Endoscopy is usually diagnostic.

Adenocarcinoma of colon usually appearsafter 10 yrs of age. Persistent vomiting, anorexia, weight loss,abdominal pain, and GI bleeding are common manifestations. Contrastenema and colonoscopy with biopsy are diagnostic.

Rectum and Anus

Anal Fissure

Common causeof blood-streaked stools in neonates and young infants. Common causesare trauma from passage of hard stool and frequent use of rectalthermometer.

Stretching anal skin enables fissureto be visualized.

Trauma

Any foreignbody placed in rectum may cause trauma and bleeding.

History and physical exam are usuallydiagnostic, but proctoscopy may be needed in some cases. Plain radiographsof lower abdomen and pelvis can demonstrate radiopaque objects.

Sexual Abuse

Rectal trauma and bleeding may occur as resultof sexual abuse. History, physical exam, and proctoscopy are diagnostic.

Hemorrhoids

Defined as thrombosed collections of bloodvessels in anal area, which are uncommon in infancy and childhood.Usual cause is chronic constipation.

Other

Other causes of GI bleeding are swallowedblood, coagulopathy, and drugs.

Factitious Bleeding

Factitioushematemesis, hematochezia, or melena may be seen with various foods, medications,and artificial food colorings.

Commercial dyes no. 2 and no. 3 foundin breakfast cereals and fruit drinks may produce reddish colorof vomitus or stool.

Certain substances produce blackishcolor of stools: iron preparations, licorice, blueberries, beets,lead, charcoal, and bismuth.

In Munchausen syndrome by proxy, emesisor stool may be contaminated with blood that is not the child's.

Diagnostic Approach

Determination of Gastrointestinal Bleeding

Determinewhether reddish color of vomitus or stool is blood (e.g., raspberries,beets, and food colorings can give reddish color).

Gastroccult (Smith Kline Diagnostics,San Jose, CA) test may be used to detect presence of blood in vomitusor gastric aspirate. Hemoccult test can be used to confirm presenceof blood in stool.

Severity of Bleeding

If GI bleedingis obvious, most important task is to determine severity.

Important to quantitate amount of bleeding:1–2 drops, 1 teaspoonful, 1 cupful, or massive bleedingwith clot formation. Passage of clots via rectum or vomiting of >1cupful of bright red blood is indicative of significant bleeding.

In such cases, first note vital signsand perform any necessary resuscitation.

Immediate fluid replacement is requiredto stabilize BP.

Site of the Bleeding

Determinethe site of bleeding—whether it is from the upper or lowertract or both. Blood from nose or mouth can be swallowed and subsequentlyvomited or passed in stool. Retching from vomiting also can producesome blood-stained vomitus but is rarely severe.

Except in these instances, NG tubeshould be placed to document level and rate of bleeding.

Gastric aspirate that is positive forblood is highly specific for upper tract bleeding. Negative aspiratesuggests lower tract bleeding but does not totally preclude uppertract bleeding, especially from duodenum.

Specific Diagnosis

Importantfactors to consider in diagnosis are

Age

Clinical findings (e.g., vomiting,diarrhea, fever, constipation, abdominal pain, hepatomegaly, splenomegaly,abdominal distension, weight loss, and jaundice)

History of aspirin, NSAID, or alcoholingestion

Presence of known diseases (e.g., IBDor liver disease)

Diagnostic studies that may identifysource of acute bleeding include endoscopy, radionuclide scanning,and selective angiography.

If upper tract bleeding has stoppedor is intermittent, upper endoscopy can be performed to diagnoseesophagitis, gastritis, gastric or duodenal ulcer, Mallory-Weisstear, and esophageal varices.

If endoscopic exam is impossible to performbecause of continuous bleeding, radionuclide scan or selective angiographycan be performed. Technetium sulfur colloid scan can detect slow ongoingbleeding, whereas technetium red cell scan can detect slow intermittentbleeding. These techniques help localize site of bleeding, so thatother diagnostic studies can be performed.

Sulfur colloid scan can detect bleedingat rate as low as 0.1 mL/min, but only if bleeding is occurringat time of injection because half-life of tracer is <2.5mins. Labeled red cells remain in blood for 24 hrs, so technetiumred cell scan can detect intermittent bleeding.

If these scans fail to disclose siteof bleeding or bleeding is brisk, selective angiography should beperformed—angiography of celiac axis and superior mesentericartery for suspected upper tract bleeding, and superior mesentericand inferior mesenteric artery angiography for suspected lower tract bleeding.

Another advantage of angiography isthat therapeutic measures (e.g., vasopressin infusion and embolization)can be used if necessary.

If the bleeding is massive or uncontrolled,immediate surgery should be considered.

In stable child with lower tract bleeding,anus should be examined for anal fissure and rectum for polyp.

With bloodydiarrhea, bacterial stool culture should be performed, and examof stool for ova and parasites should be considered.

Technetium 99m–pertechnetatescan to identify ectopic gastric mucosa in Meckel diverticulum orintestinal duplication also should be considered. If diagnosis remainsuncertain, proctosigmoidoscopy should be performed. This may befollowed by colonoscopy or contrast studies.

Colonoscopy with biopsy may diagnosepolyps, colitis, IBD, hemangiomas, and malignant lesions. Air-contrastenema may diagnose intussusception.

With persistent undefined bleeding,upper tract endoscopy may be useful to identify ulcer, esophagealor gastric varices, or vascular lesion.

Upper GI radiographic series with smallbowel follow-through may diagnose lesions of esophagus, stomach,and duodenum as well as lesions of small bowel, including Crohndisease

Selective angiography may not revealsite of bleeding if bleeding is too slow, but it may suggest angiodysplasticlesion or tumor by revealing abnormal vascular pattern.

>

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Melena: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient's condition permits, ask when he discovered that his stools were black and tarry. Ask about the frequency and quantity of bowel movements. Has he had melena before? Ask about other signs and symptoms, notably hematemesis or hematochezia, and about use of anti-inflammatories, alcohol, or other GI irritants. Also, find out if he has a history of GI lesions. Ask if the patient takes iron supplements, which may also cause black stools. Obtain a drug history, noting the use of warfarin or other anticoagulants.

Next, inspect the patient's mouth and nasopharynx for evidence of bleeding. Perform an abdominal examination that includes inspection, auscultation, palpation, and percussion. Then perform a rectal examination.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Rectal pain: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Begin by taking the patient's history. Ask him to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

Be sure to ask appropriate questions about the development of associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stools, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he's experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary and drug history.

Then inspect the rectal area for bleeding; abnormal drainage, such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Hematochezia [Rectal bleeding]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If hematochezia isn't immediately life-threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.

Next, explore the patient's medical history, focusing on GI and coagulation disorders. Ask about the use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs (NSAIDs).

Begin the physical examination by checking for orthostatic hypotension, an early sign of shock. Take the patient's blood pressure and pulse while he's lying down, sitting, and standing. If systolic pressure decreases by 10 mm Hg or more or if the pulse rate increases by 10 beats/minute or more when he changes position, suspect volume depletion and impending shock.

Examine the skin for petechiae or spider angiomas. Palpate the abdomen for tenderness, pain, or masses. Also note lymphadenopathy. Finally, a digital rectal examination must be done to rule out rectal masses or hemorrhoids.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Vaginal bleeding, postmenopausal: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Determine the patient's age and her age at menopause. Ask when she first noticed the abnormal bleeding then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her menses regular? If not, ask her to describe menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient's mother and ask about a family history of gynecologic cancer. Determine whether the patient has associated symptoms and if she's taking estrogen.

Observe the external genitalia, noting the character of vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient's breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

RECTAL BLEEDING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Armed with a more comprehensive list of causes of rectal bleeding, the clinician is ready to eliminate some of them as he or she asks appropriate questions during the history and performs the examination with all the causes in mind. The diagnosis may be pinned down by the presence or absence of other symptoms and signs. The principal diagnostic procedures are stool cultures, stool examination for ova and parasites, proctoscopy, barium enema, and colonoscopy.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

RECTAL PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The cause of rectal pain is usually obvious on examination with an anoscope or proctoscope. Careful palpation may be necessary to discover a perirectal abscess, coccydynia, or an ectopic pregnancy. Anal fissures may be missed unless all quadrants of the anus are examined with the slit anoscope.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

HEMATEMESIS AND MELENA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

When confronted with solid evidence of hematemesis, the clinician should not waste valuable time on a thorough history and physical examination when endoscopy is more important in both diagnosis and therapy. Ordering a type and cross for multiple units of blood, coagulation studies, and the other tests listed below should also be done immediately in most cases. History of alcoholism, use of aspirin and other drugs, and previous ulcers or esophageal disease is important to get while preparing for endoscopy and other emergency procedures. Patients without massive or recent acute hematemesis may be approached with traditional methods. A history of vomiting nonhemorrhagic gastric fluid before the onset of hematemesis is helpful in diagnosing a Mallory–Weiss syndrome.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Lower GI Bleeding: Lower GI Bleeding - DIAGNOSIS
(The 5-Minute Pediatric Consult)

• General goals: Determine location of bleeding and the cause, and begin stabilization and treatment.
  • Phase 1: Determine if there is blood or other cause of red or black stools.
  • Phase 2: Assess patient to determine etiology; follow history, physical, and laboratory.
  • Phase 3: Stabilize patient, decide if emergency treatment or referral is needed. (See “Emergency Care” under “Treatment.”)
• Hints for screening problem:
  • The more rapid the rate, the larger the volume of lower GI bleeding, and greater the drop in hemoglobin and change in pulse and BP.
  • Any significant blood loss will lead to pallor, tachycardia, orthostasis, poor capillary refill, CNS changes (restlessness, confusion), and hypotension.
  • Hypotension may not be seen even in the face of significant blood loss, because vasoconstriction will occur to maintain BP until decompensation.
  • Initial hemoglobin values may be unreliable, because a delay in hemodilution may falsely result in near-normal values.
  • In newborn, determine if this is swallowed maternal blood by the Apt-Downey test.

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

Upper Gastrointestinal Bleeding: Upper Gastrointestinal Bleeding - DIAGNOSIS
(The 5-Minute Pediatric Consult)

• Approach to the patient:
  • General goals:
    • Determine the cause of the bleeding and begin treatment.
    • Place NG tube and lavage contents of stomach to determine if bleeding is active, and extent of bleeding.
    • Phase 1: Determine whether the emesis contains blood, such as red food coloring, fruit-flavored drinks and juices, vegetables, and some medicines may resemble blood. A pH-buffered Gastroccult test identifies blood in the vomitus or gastric aspirate.
    • Phase 2: Assess severity of bleeding. Is there a change in vital signs, hematocrit, BPs, capillary filling, pulse?
    • Phase 3: Determine the site of bleeding and begin treatment. Examine airway for bleeding: Epistaxis may contaminate emesis to make it resemble upper GI bleeding. Usually diagnosis requires imaging or endoscopy.
• Hints for screening problem:
  • Bright red blood signifies active bleeding.
  • Darker blood or coffee grounds blood usually means that the blood has had some time to become denatured by gastric acid.
  • The rate of bleeding determines the clinical presentation. The more rapid the rate, the larger the volume of bleeding, leading to a greater drop in hemoglobin and change in pulse and blood pressure. Slower bleeding usually presents with anemia and heme-positive stools.
  • Any significant blood loss will lead to pallor, tachycardia, orthostasis, poor capillary refill, CNS changes (e.g., restlessness, confusion), and hypotension.
    • Hypotension is a late sign and may not be present even with significant blood loss because vasoconstriction maintains blood pressure until decompensation occurs.
  • Initial hemoglobin values may be unreliable because a delay in hemodilution may falsely produce near normal values.
  • Absence of blood in the emesis or in nasogastric lavage fluid does not rule out the upper GI tract as the site of bleeding, because a competent pylorus may mask bleeding from a duodenal site.
    • In some cases of massive upper GI bleeding, the patient may not vomit blood but may pass large, black, tarry, or sticky stools (e.g., melena).

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

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