Brbpr

[Aina]

Patient with painful BM and streaks of blood on toilet paper after starting opiate for fracture 2 days ago. Hard stools for 2 days. Never had similar symptoms. Does anyone know if anal fissure or hemorrhoid would be more likely?

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[Gastrapathy]

Patient with painful BM and streaks of blood on toilet paper after starting opiate for fracture 2 days ago. Hard stools for 2 days. Never had similar symptoms. Does anyone know if anal fissure or hemorrhoid would be more likely?

Either is fairly likely. Also in your differential are colon cancer, diverticulosis, AVM's, IBD, ischemic colitis (likely in an old post-op pt) etc. If pt is <40 (some would say 35) and otherwise average risk for colon cancer, this can be evaluated with a quick flex. Otherwise the pt needs colonoscopy. Even if you see a hemorrhoid that you think explains the bleeding, BRBPR=further eval of some type. However, for the sake of your inpatient GI service, there is no indiciation for inpt consultation. All of this can be done with a quick outpt referral.

 

[DrWBD]

However, for the sake of your inpatient GI service, there is no indiciation for inpt consultation. All of this can be done with a quick outpt referral.

Yes, an inpatient consult for this might precipitate "GI Upset".
http://www.qfever.com/issues/20030702/medstud.html

 

[Vision]

what happent to scope them if you got them? hemostasis case is more exciting then plain ol' screening wouldn't u agree?

Nothing beats three hemoclip in the middle of night stopping a squirter!

Either is fairly likely. Also in your differential are colon cancer, diverticulosis, AVM's, IBD, ischemic colitis (likely in an old post-op pt) etc. If pt is <40 (some would say 35) and otherwise average risk for colon cancer, this can be evaluated with a quick flex. Otherwise the pt needs colonoscopy. Even if you see a hemorrhoid that you think explains the bleeding, BRBPR=further eval of some type. However, for the sake of your inpatient GI service, there is no indiciation for inpt consultation. All of this can be done with a quick outpt referral.

 

[Gastrapathy]

what happent to scope them if you got them? hemostasis case is more exciting then plain ol' screening wouldn't u agree?

Nothing beats three hemoclip in the middle of night stopping a squirter!

You bet I want that procedure, thats just incredibly uncommon with LGIBs. Tell me the patient has melena, hematemesis, coffee grounds on NG lavage and I'm game. But a little BRBPR is not going to be an active bleed nearly ever.

 

[Vision]

Don't forget that 20% fast uppers. Jensen etal 1998 i think

You bet I want that procedure, thats just incredibly uncommon with LGIBs. Tell me the patient has melena, hematemesis, coffee grounds on NG lavage and I'm game. But a little BRBPR is not going to be an active bleed nearly ever.

 

[Gastrapathy]

Don't forget that 20% fast uppers. Jensen etal 1998 i think

Look back at the history, sounds like a little blood on the paper. A patient with BRB from an upper is BLEEDING and will act like it. I want that procedure too (in fact, I want this patient's colonoscopy, just scheduled in my clinic rather than in the hospital).