Tutorial Approach
Module on Child Neglect


Teaching Modules



     At the end of this module, the student should be able to:
     1. Diagnose the cause and distinguish a lower GI bleed from an upper GI bleed
     2. Outline the physiologic response to acute massive lower GI bleed
     3. Propose medical or surgical management plan for lower GI bleed
     4. Advise patient for diagnostic and management options to GI bleed
     5. Describe and perform appropriate procedure like NGT insertion and rectal examination



To achieve the terminal objectives, the students should know the:

          A.  Biological Perspective
                                 Anatomy of the Lower GI from the ligament of Treitz to anus ( Gross and Microscopic)
                                 Trace vascular Supply of the lower GI
                                Outline of the physiologic response to massive GI bleeding
                                Time required for fluid shift in response to GI bleed
                                Role and limitation for measurement of hemoglobin and Hematocrit in acute GI bleeding
                                Physiologic estimation of blood loss
                                Immunologic basis for blood typing
                               Guaiac stool test for occult blood - biochemical basis
                               List the important cause of GI bleeding and their respective mechanism for bleeding
                                         Colonic Ca
                                         Ulcerative colitis
                                         Inflammatory bowels syndrome
                                         Infectious colitis - amoebic colitis
                                         Meckel's Diverticulum
                                         Anal Fissure
                              Pitfalls in the microsocpic diagnosis of amoebiasis
                              Anti-amoebic drugs - pharmacokinetics and indications
                              Use of fresh frozen plasma
                              Antibiotics role in diverticulitis

                              Outline the emergency management of patient with massive 
                              GI bleed
                              Understand how the patient is prepared for and monitored during blood transfusion
                              State the indication for transfusion of uncross-matched 
                                   blood and blood type utilized if the patients  
                                   blood type is unknown       
                              Tilt Test- significance , indication and contraindication
                              Diagnostic approach to diagnosis of LGI bleed
                                    Barium Enema - double air contrast
                                    Arteriography - angiography
                                    Tc-SC scan
                             Treatment options and the choice of haemostatic modality
                                   Endoscopic diathermy
                                   laser coagulation
                                   injection sclerotherapy
                             Surgical treatment criteria ( indication for surgery)
                             High fiber diet role 

               B.  Behavioral Perspective
                            Medico-ethical issues on emergency blood transfusion
                           Understanding the feelings of patient as regards to diagnostic procedure ( their fear and anxiety )

                     Indications for NGT insertion
                     Indication for rectal examination
                     Procedural steps for NGT insertion
                    Choice of appropriate size of NGT

             III.  COMMUNITY STRAND 
                     Population at risk for Lower GI bleeding
                     Community Health plan for the control of amoebic colitis in the community

Trigger 1

    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?
List your 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 prompts:

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 blood?
             What is the difference between melena and tarry stools?
             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 entities:
            Infection/inflammation - shigellosis, amoebiasis, colitis
           Parasitic infestations - pinworms 
           Anal and rectal lesions - hemorrhoids, fissures
           Colonic lesions - angiodysplasia, polyps, cancer
           Esophageal varices
           Stress Ulcers

Learning Goals:
      1. Different diseases causing bleeding from the lower GI. 
      2. Clinical differentiation between UGIB and LGIB
      3. Clinical Manifestations
      4. Etiopathogenesis of GIB

Trigger 2 

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 hypertension.

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.

Tutors Prompt:
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 cover

          1. Significance of the amount of bleeding? Frequency of bleeding
          2. Effect of bleeding on the patient.. hemodynamically..
          3. What is the significance of the history of bleeding episode before?
          4. Is the hypertension a risk factor?
          5. Systemic 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.. ischemia)

Trigger 3

The physical examination of the patient:

              Elderly female, undernourished, conscious, coherent, ambulatory not
              in distress with the following vital signs:

             BP = 180/100                HR = 80/min             RR = 22/min

                      Head and Neck : pinkish palpebral conjunctiva 
                               anicteric sclera
                               supple neck
                     Chest : clear breath sounds: (-) crackles
                     Heart : regular rate and rhythm; no murmurs
                     Abdomen flat, soft, (-) organomegaly
                     Rectal Exam : good tone; (-) tenderness, (+) blood on the examining 
                                finger: no external 
                                hemorrhoids; no masses

Tutor Prompts 
1. Ask students to review and re-rank hypothesis in the light of new information from the P.E.
2. Discuss 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.
4. Change scenario to a massive bleeding episode with hypotension, tachycardia .. pallor

Learning Goals

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?
Paraclinical diagnostic procedures 
Indications, accuracy, complications

Trigger 4

The following laboratories were ordered by the admitting physician:
CBC, CT, BT, blood typing, platelet count
ECG 12 leads
FBS, creatinine, uric acid, cholesterol, triglycerides
Occult blood
The patient was hooked with an IV fluid and blood was requested.

Medications given included:
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 hematochezia.

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 patient
                            Prompt the student to interpret it
                            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 case?
3. What is tranexamic acid? Its action and side effects, if any.

Learning Goals

1. Rational use of paraclinicals tests 
      Occult blood in stools, significance.
      Specificity and accuracy of such test. e.g. false negative 
2. Action, indications and side effects of tranexamic acid and other hemostatic agents.

Laboratories Results

               CBC                             FBS = 4.0
               Hgb 8                            BUN = 7
               Hct 24                           Creatinine = 80
              WBC 5000 x 10            Uric acid = 220
                   neutrophils .60                Cholesterol = NA
                  lymphocytes.20               Triglycerides = NA

              CT normal
              BT normal
              Platelet 250,000

Chest x-ray : Atheromatous aorta
residual lung fibrosis

Barium enema ; Multiple diverticulosis with occasional signs of spasticity.
Incidentally pelvic cavity calcification. Merits ultrasound correlation.
(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 is intact.
No adnexal mass seen.
Impression ; Normal uterus and adnexa.

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.
2. Give feedback on their summary( if they are focused, brief and concise.)
3. Ask 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?
6. If the diverticulitis were not that extensive, would the treatment approach differ?
7. Why did this patient have no abdominal pain symptoms in the past considering she has a very extensive multiple diverticulosis?
8. Does 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 indicated?

Learning Goals

1. Rational, logical approach to a diagnosis - diverticulosis
2. Advice about treatment and treatment modalities.
3. Etiopathology of diverticulitis. How do they come about?
4. Complications of diverticulosis

Trigger 5

The patient 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 excised.

The patient had a stormy postoperative course but eventually improved and was discharged well. The patient is now still alive and doing well.

Tutors Prompt

Post operatively. what complications do you antecepate after surgery?
e.g. Vit B12 absorption and others.
Can this surgical resection affect fat digestion and absorption postoperatively?
How would you care for the nutrition of this patient?

Trigger 6 : Behavioral and Population Perspective

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?
How would you address these concerns?
How far should you go to support this patient?
What is the limit of your role?

2. How common is GIT bleeding? Which group of population are susceptible to this syndrome? Why?

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 them?


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