• Where do you often see a massive bleed?

  In patients that are 65 years and older with multiple comorbidities and are on antiplatelets and anti-coagulants.
• How would a patient with a massive bleed present?

  haematochezia.

  low blood pressure.

  pulse of more than 100.

  low urine output.

  Hb less than 6g/dL.
• What are the causes of massive bleeds?

  diverticular disease.

  AV malformation.

  dieulafoy's vessel.
• What is characteristic of moderate bleeding?

  can present at any age.

  it usually presents with haematochezia/melena and the patient is haemodynamically stable.
• What are the causes of moderate bleeding?

  benign.

  infections.

  inflammations.

  neoplasm.
• What is characteristic of occult bleeding?

  can occur at any age.

  it is chronic and usually presents with microcytic hypochromic anemia and a positive occult stool test.
• What are the causes of occult bleeding?

  congenital.

  inflammatory.

  neoplasm.
• Where do the majority of lower GIT bleeds originate?

  distal to IC valve.
• What are the characteristics of diverticular disease?

  presents with painless haematochezia.

  majority stop spontaneously.

  occurs in older patients.

  mostly affects the left colon.
• What are the characteristics of Dieulafoy's disease?


  the large artery below the mucosa ruptures spontaneously causing a massive bleed.
• What are the characteristics of ischaemic colitis?

  occurs in the elderly.

  due to reduced mesenteric flow to the colon due to cardiac failure, vasospasms, and atherosclerosis.

  water shed areas are affected.
• What are the causes of lower GI bleeds in patients 50 and younger?

  haemorrhoids.

  IBD.

  vascular ectasia.

  NSAID use.
• What are the lab tests for lower GI bleeds?

  FBC.

  U&E.

  lactate.

  coagulation studies.
• Discuss the evaluation triage of lower GI bleeds.


  ABC.

  02.

  two large bore peripheral IV drip.

  ECG.

  crystalloids IV.

  blood transfusions.
• Discuss the BLEED criteria for lower GI bleeds.

  ongoing Bleed.

  Low BP.

  Elevated.

  Erratic mental state.

  unstable comorbid Disease.
• How are lower GI bleeds treated?

  it is a multi-disciplinary approach.

  colonoscopy that should be done within 24 hours of the bowel being prepped.

  for diverticular disease, administer 1:10000 at 1mL of adrenalin and inject 1-2mL at site.

  if the patient is unstable, then administer 3-5 mLs of CTA with sensitivity set at 85%.

  cath angio in unstable patients with ongoing bleed.

  radionuclide 99TC in scant
• When is surgery indicated in patients with lower GI bleeds?

  haemodynamic instability.

  more than 6 units of blood in 24 hours.

  not responding to resuscitation.

  an emergency segmental resection or subtotal colectomy is done.
• How is angio dysplasia treated?

  sclerotherapy.

  argon plasma beam.

  clip.
• How are internal haemorrhoids treated?

  rubber band ligation.
• Where is diverticular disease mainly found?

  sigmoid colon.
• True or false: 80% of diverticular diseased patients are asymptomatic.

  true.
• What are the symptoms of diverticulitis usually due to?

  complications.
• What are the symptoms of diverticulitis?

  left iliac fossa pains.

  fever.

  mass.

  tenderness.
• What are the radiological features of diverticulitis?

  barium contraindicated.

  free air.

  localized ileus.

  lower quadrant mass.
• What are the complications of diverticulitis?

  perforation.

  abscess.

  fistulas.

  obstruction.
• Discuss diverticulitis according to the Hinchey classification.


  type I - pericolic abscess or phlegmon.

  type II - pelvic, intra-abdominal or retroperitoneal abscess.

  type III - generalized purulent peritonitis.

  type IV - generalized faecal peritonitis.
• Discuss the medical management of diverticulitis.

  hospitalize.

  antibiotics.

  analgesics.

  IV fluids.

  there is recurrence in a third of the patients.
• Discuss the surgical management of diverticulitis.

  primary resection with anastomosis - oedematous bowel and gross contamination.

  primary resection without anastomosis - resect diseased bowel, colostomy, and then close stoma later.

  3 stage procedure - transverse colon done and abscess drainage, the drain is left in place and the perforation is closed, the left colon is then resected and thusly the colostomy is closed.
• When is surgery in diverticulitis indicated? [IPPRY]

  inability to rule out carcinoma.

  persistent diverticulitis.

  phlegmon or other complications.

  recurrent diverticulitis.

  younger patients.
• What is the most common diverticulosis?

  colonic diverticulosis.
• What is the presenting symptom of colovesical fistulas in diverticulitis?

  UTIs.
• What are the other symptoms of a colovesical fistula in diverticulitis?

  faecaluria.

  pneumaturia.
• Name the fistulas of complicated diverticulitis?

  colovesical.

  colo-enteric.

  colovaginal.

  colocutaneous.
• When does a colocutaneous fistula present in complicated diverticulitis?

  it is spontaneous, usually after percutaneous drainage.
• What investigations would you use for a haemorrhage in diverticulitis? [BPCAN]

  barium.

  proctoscopy/sigmoidoscopy.

  colonoscopy.

  angiography.

  nuclear scans.
• What are the blood investigations you would do for diverticulitis?

  FBC.

  U&E.

  CRP.

  albumin.
• What is the purpose of an erect chest X-ray in the evaluation for diverticulitis?


  to rule out free air.
• Why is an abdominal CT scan the gold standard for diagnosing diverticulitis? [SWASH]


  site of diverticular.

  whether it is inflamed or not.

  abscess or not.

  size and location of abscess.

  Hinchey classification.
• How is Hinchey type I diverticulitis treated?

  antibiotics.

  analgesics.

  monitor clinical presentation and bloods.

  feed if tolerable.
• How is Hinchey type II diverticulitis treated?

  if the abscess is less than 4cm in diameter, treat with antibiotics, analgesics, monitor clinical presentation and bloods, and feed if tolerable.

  if abscess is more than 4cm in diameter, then treat with antibiotics, analgesics, monitor clinical presentation and blood, and feed if tolerable, and also drainage of abscess.