At the end of this module, the student should be
Diagnose the cause and distinguish a lower GI bleed from an upper GI
2. Outline the physiologic response to acute
massive lower GI bleed
3. Propose medical or
surgical management plan for lower GI bleed
Advise patient for diagnostic and management options to GI
5. Describe and perform appropriate procedure
like NGT insertion and rectal examination
I. WORKING PROBLEM
the terminal objectives, the students should
Anatomy of the Lower GI from the ligament of Treitz to anus ( Gross and
Trace vascular Supply of the lower
Outline of the physiologic response to massive GI
Time required for fluid shift in response to GI
Role and limitation for measurement of hemoglobin and Hematocrit in acute GI
Physiologic estimation of blood
Immunologic basis for blood
Guaiac stool test for occult blood - biochemical
List the important cause of GI bleeding and their respective mechanism for
Infectious colitis - amoebic
Pitfalls in the microsocpic diagnosis of
Anti-amoebic drugs - pharmacokinetics and
Use of fresh frozen
Antibiotics role in
Outline the emergency management of patient with
Understand how the patient is prepared for and monitored during blood
State the indication for transfusion of
blood and blood type utilized if the
blood type is
Tilt Test- significance , indication and
Diagnostic approach to diagnosis of LGI
Barium Enema - double air
Treatment options and the choice of haemostatic
Surgical treatment criteria ( indication for
High fiber diet
Medico-ethical issues on
Understanding the feelings of patient as regards to diagnostic
procedure ( their fear and anxiety
II. PROFESSIONAL SKILL
Indications for NGT
Indication for rectal
Procedural steps for NGT
Choice of appropriate size of
Population at risk for Lower GI
Community Health plan for the control of amoebic colitis in the
Mrs. Tomasa Calabasa ., 69 y.o., female, retired nurse from Lustre, Z.C.,
consulted because of hematoschezia.
1. What is her problem?
2. What is hematochezia?
hypothesis as to the cause and suggest a mechanism by which the hypothesis can
lead to the presenting problem.
3. What additional information do you need
from Mrs. C.?
Questions for the tutor:
Sample questions for tutors to use as
1. What questions do you want to ask Mrs. C. regarding her
problem? Why are you asking these questions?
2. What are the anatomical
structures involved in bleeding in the intestinal tract?
3. What is the
significance of the color of the
What is the difference between melena and tarry
Maroon colored stools?
4. What does the rate of bleeding have to do with the
color of the stools or is it the length of the bowel in relation to transit
time? How about transit time?
5. Discuss the possible causes - mechanism of
bleeding in the following
Infection/inflammation - shigellosis, amoebiasis,
Parasitic infestations -
Anal and rectal lesions - hemorrhoids,
lesions - angiodysplasia, polyps,
Different diseases causing bleeding from the lower
2. Clinical differentiation between
UGIB and LGIB
4. Etiopathogenesis of
Her condition was noted a
few hours prior to admission when the patient complained of hematochezia of
three episodes amounting to a cupful per episode. There was no alteration in
urination. There was no cough, chest pain nor fever.
The patient was
admitted to a private hospital about a year ago because of lower GI bleeding and
several times at another hospital because of essential
There is a history of diabetes in the family. The patient
denies smoking nor drinking alcoholic beverages.
There was no recent
intake of any medications.
1. Lead the students to reformulate
their earlier hypothesis based on the new information.
2. Why did you
reformulate your hypothesis that way?
3. What other information would you
require at this time?
Potential Learning issues to
Significance of the amount of bleeding? Frequency of
2. Effect of
bleeding on the patient..
What is the significance of the history of bleeding episode
4. Is the
hypertension a risk
versus local cause of bleeding?
Prompts to help students inter-connect
learning issues from other modules with this case.
1. Risk factor for
bleeding from the gastrointestinal tract.
2. Hypertension and vascular
accidents (SMA thrombosis... intestinal angina..
The physical examination of
Elderly female, undernourished, conscious, coherent, ambulatory
in distress with the following vital
Head and Neck : pinkish palpebral
Chest : clear breath sounds: (-)
Heart : regular rate and rhythm; no
Abdomen flat, soft, (-)
Rectal Exam : good tone; (-) tenderness, (+) blood on the
hemorrhoids; no masses
1. Ask students to review and re-rank
hypothesis in the light of new information from the P.E.
ano-rectal lesions which can be seen and palpated.
3. Discuss how they would
like to work this patient up if they were the attending physician.
scenario to a massive bleeding episode with hypotension, tachycardia ..
Review the resuscitative measures for a
patient with lower GI bleeding.
Correlate issues learned in ther
modules like shock due to hemorrhage, or burns.
When is the bleeding
considered massive? Assessment of blood loss.
Review replacement and
maintenance of blood volume.
When do we call in the surgeon?
Why do we
have to call a surgeon?
What about endoscopist?
laboratories were ordered by the admitting physician:
CBC, CT, BT, blood
typing, platelet count
ECG 12 leads
FBS, creatinine, uric acid,
The patient was
hooked with an IV fluid and blood was requested.
Nifedipine 5 mg. SL
Tranexamic acid 500 mg IVTT now then 500
mg capsule 3 x a day
Orders for monitoring the amount and frequency of
On referral to the department of surgery on the same
day, the following laboratories were ordered:
Barium enema - Show
the X-ray plates of this
Prompt the student to interpret
Review with them how to identify Colon from Intestines
Questions for Tutors:
1. Comment on the paraclinicals
ordered. Suggest a rationale for each.
2. What would you have done in this
3. What is tranexamic acid? Its action and side effects, if
1. Rational use of paraclinicals
Occult blood in stools,
Specificity and accuracy of such
test. e.g. false negative
2. Action, indications and side effects of
tranexamic acid and other hemostatic
WBC 5000 x 10
Uric acid =
Chest x-ray : Atheromatous aorta
Barium enema ; Multiple diverticulosis with occasional
signs of spasticity.
Incidentally pelvic cavity calcification. Merits
(plates available for viewing at the deans office).
Request the students to rationalize how air-contrast media radiology is achieved
and its rationale.
Ultrasound, pelvis : Uterus is small measuring
4.6 x 2.2 x 1.7 c and is normal with the age of the patient. Endometrial stripe
No adnexal mass seen.
Impression ; Normal uterus and
ECG : within normal limits
Prompts for the Tutors:
1. Review the case. Ask
the student to make a brief summary of the case, or an algorithm.
feedback on their summary( if they are focused, brief and concise.)
them to interpret the lab. results and how it helped them in their impression of
the case so far.
4. Inquire students on the modality of treatment for this
patient. Are there other options? Advantages and disadvantages of one option
over the other in terms of risks and complications.
5. How would they advise
this patient regarding treatment. How would you treat the anemia here?
the diverticulitis were not that extensive, would the treatment approach
7. Why did this patient have no abdominal pain symptoms in the past
considering she has a very extensive multiple diverticulosis?
diverticulosis aftect digestion and absorption of nutrients?
9. What is the
relationship between diverticulosis and the intestinal gut flora?
10. Why was
a pelvic examination/ultrasound done here? was it
1. Rational, logical approach to a
diagnosis - diverticulosis
2. Advice about treatment and treatment
3. Etiopathology of diverticulitis. How do they come about?
Complications of diverticulosis
underwent exploratory laparotomy with resection of the descending colon,
tranverse colon and the distal descending colon with primary anastomosis. The
calcification in the pelvis turned out to be serosal myomas which were
The patient had a stormy postoperative course but eventually
improved and was discharged well. The patient is now still alive and doing
Post operatively. what complications
do you antecepate after surgery?
e.g. Vit B12 absorption and others.
this surgical resection affect fat digestion and absorption
How would you care for the nutrition of this
Trigger 6 : Behavioral and Population
1. This experience of seeing blood in the stools is very
frightening to the patient . Even more so the fact to be told that she has to
undergo resection of the entire colon practically.
What possible concern
do you think the patient has? How can you help her verbalize these?
you address these concerns?
How far should you go to support this
What is the limit of your role?
2. How common is GIT
bleeding? Which group of population are susceptible to this syndrome?
3. Are there any risk factors that you can think of that may be
forerunners to GIT bleeding ? Health habits or behavior? How would you address