Lower gastrointestinal bleeding

Rationale

Lower gastrointestinal bleeding is defined as blood originating distal to the ligament of Treitz. It can present as frank bleeding (e.g., hematochezia) or as occult blood loss. Although commonly seen in benign conditions, it may be the first presentation of malignancy.

Causal Conditions

(list not exhaustive)

1. Vascular (e.g., diverticulosis, angiodysplasia, ischemia, postprocedure)
2. Inflammatory (e.g., infection, inflammatory bowel disease, ulcerative colitis)
3. Neoplastic (e.g., polyp, carcinoma)
4. Anorectal disease (e.g., rectal ulcer, trauma, hemorrhoids, anal fissure)
5. Brisk bleeding from the upper gastrointestinal tract

Key Objectives

Given a patient presenting with lower gastrointestinal bleeding, the candidate will diagnose the cause, severity, and complications, and initiate an appropriate management plan. Particular attention should be given to the hemodynamic status of the patient and the need for immediate specialized care. The candidate will also identify patients who are at high risk for colorectal cancer for a screening colonoscopy.

Enabling Objectives

Given a patient with lower gastrointestinal bleeding, the candidate will

1. list and interpret critical clinical findings, including those based on
   1. a history and a physical examination, including a rectal examination as part of the initial assessment, and
   2. the patient’s hemodynamic status;
2. Assess the need for critical clinical investigations and interpret their results, including a
   1. sigmoidoscopy or colonoscopy, and/or
   2. laboratory tests and diagnostic imaging as appropriate;
3. construct an effective initial management plan, including determining whether the patient needs immediate resuscitation and/or specialized care.