Diagnosis and Initial Management

In all patients with lower GI bleeding, fluid resuscitation and correction of coagulopathy or thrombocytopenia take precedence over diagnostic or therapeutic procedures. Nasogastric (NG) lavage is performed looking for fresh blood, clots, or "coffee grounds" suggestive of an upper GI source. The absence of blood on NG lavage does not exclude upper GI bleeding, unless bile is obtained. Evaluation of the anorectum should include digital rectal exam and anoscopy. The latter will allow identification of internal hemorrhoids, fissures, or fistulas. After this point, the decision between further diagnostic studies will depend on the severity of bleeding, overall condition of the patient and comorbid diseases, and the availability of each diagnostic tool in a specific hospital. Available options include colonoscopy, tagged red blood cell (RBC) scan, and

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FIGURE 101-1. Algorithm for the management of lower gastrointestinal bleeding. EGD = Esophagogastroduodenoscopy; NG = nasogastric; RBC = red blood cells.

angiography. Contrast radiology (barium enema) has been shown in multiple studies to have a low diagnostic yield for localizing a colonic bleeding source, and interferes with subsequent attempts to perform colonoscopy and angiography. Barium enema it is not recommended as part of the evaluation of acute lower GI bleeding. Capsule endoscopy is a recent option for evaluating recurrent acute hemorrhage of possible small bowel origin. This is discussed in the chapter on occult bleeding (see Chapter 59, "Obscure Gastrointestinal Bleedings").

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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