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This continuing medical education self-study monograph, “Know Your Probiotics in Gastrointestinal Disorders: No Two Are The Same,” is certified for physicians. This activity is designed for internal medicine physicians, family medicine physicians, gastroenterologists, nurse practitioners, and physician assistants involved in the care of patients with gastrointestinal disorders. This activity will outline what is currently known about probiotics in IBD, IBS and diarrhea, and will aid healthcare professionals in selecting an appropriate treatment for a given patient, thereby achieving improved health outcomes.
Outline the clinical conditions that have been shown to benefit from the use of probiotics. Based on current clinical trial evidence, select an appropriate probiotic product to treat a given patient. There are no fees for participating and receiving continuing medical education (CME) credit for this activity. Upon registering and successfully completing the post-test (score of 70% or better) and the activity evaluation, your certificate will be made available immediately. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Postgraduate Institute for Medicine and RMEI, LLC.
The Postgraduate Institute for Medicine (PIM) assesses conflict of interest with its instructors, planners, managers and other individuals who are in a position to control the content of CME activities. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of PIM, RMEI, LLC, or Sigma-Tau Pharmaceuticals. Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. MRA Magnetic Resonance Angiography or Celiac Vessels Angiography or Radioisotopic Scintiscan should identify the bleeding source.
Have a Coagulation Profile with PT, INR, PTT, Platelets, Coombs Positive and negative and Hematologist consult as well. Bleeding from diverticular disease has been reported as the most common reason for massive lower GI bleeding in most of the single-institution publications. Many other causes of lower GI bleeding have been documented, including hemorrhage from small bowel diverticulosis, Dieulafoy lesions of the colon or small bowel, portal colopathy with colonic and rectal varices, endometriosis, solitary rectal ulcer syndrome, and vasculitides with small bowel or colonic ulcerations (see Rare causes of lower GI bleeding). Surgical treatment is indicated if the patient continues to bleed and if nonoperative management is unsuccessful or unavailable. No contraindications exist with regard to surgery in hemodynamically unstable patients with active bleeding. These GI disorders are debilitating and characterized by diarrhea, abdominal pain and weight loss (Crohn’s disease) and diarrhea with rectal bleeding (ulcerative colitis).
Processing credit requests online will reduce the amount of paper used by nearly 100,000 sheets per year. The Postgraduate Institute for Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Physicians should only claim credit commensurate with the extent of their participation in the activity.
All relevant conflicts of interest that are identified are thoroughly vetted by PIM for fair balance, scientific objectivity of studies utilized in this activity, and patient care recommendations. Floch, MD, MACG, FACP, AGAF, has an affiliation with Sigma-Tau Pharmaceuticals (Honoraria), Shire (Honoraria), and Dannon (Honoraria).
PIM, RMEI, LLC, and Sigma-Tau Pharmaceuticals do not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. The information presented in this activity is not meant to serve as a guideline for patient management. Iron microparticle embolization by catheter with a vascular surgeon can non-invasively stop the source. However, the reported frequency of various other etiologies of lower GI bleeding is not consistent in these manuscripts because of the small number of cases and the highly selective referral pattern and patient populations. Approximately 50% of adults older than 60 years have radiologic evidence of diverticulosis.

Although massive lower GI bleeding manifests as maroon stools or bright red blood from the rectum, patients with massive upper GI bleeding may also present with similar findings. Segmental colectomy is indicated if the bleeding point is localized by preoperative diagnostic studies. If you wish to receive acknowledgment for completing this activity, please adhere to the following steps during the period of August 29, 2012, through August 29, 2013.
PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. Comprehensive knowledge of the etiology of lower GI bleeding is essential for patient management and, ultimately, for patient outcome. Regardless of the level of the bleeding, one of the most important elements of the management of patients with massive upper or lower GI bleeding is the initial resuscitation. Subtotal colectomy is the procedure of choice if the bleeding point cannot be localized with preoperative or intraoperative diagnostic studies.
On the other hand, the transverse and sigmoid colon are supported by a mesentery in the abdomen. It is important to understand similarities and differences amongst the probiotics that are currently available. Among the patients who underwent a diagnostic workup, the most common causes of bleeding were diverticular disease (60%), IBD (13%), and anorectal diseases (11%) (see Table 1), the figures differing somewhat from the above-mentioned study by Gayer et al. Diverticular bleeding originates from vasa rectae located in submucosa, which can rupture at the dome or the neck of the diverticulum.
These patients should receive 2 large-bore intravenous catheters and isotonic crystalloid infusions. Subtotal colectomy is associated with negligibly higher perioperative morbidity and mortality compared to segmental colonic resection. A comprehensive understanding of small bowel and colonic vascular anatomy is essential for any surgeon performing primary lower GI surgery for hemorrhage or other diseases.
Although some publications have reported arteriovenous malformations as a common cause of lower GI bleeding, the true incidence of arteriovenous malformations is insignificant (3%), as stated by Vernava et al. Meanwhile, rapid assessment of vital signs, including heart rate, systolic blood pressure, pulse pressure, and urine output, should be performed. In addition, postoperative diarrhea can be a significant problem in elderly patients who undergo subtotal colectomy and ileorectal anastomosis. The ileocolic, right colic, and middle colic branches of the superior mesenteric artery supply blood to the cecum, ascending, and proximal transverse colon, respectively. Orthostatic hypotension (ie, a blood pressure fall of >10 mm Hg) is usually indicative of blood loss of more than 1000 mL. The superior mesenteric vein drains the right side of the colon, joining the splenic vein to form the portal vein. The inferior mesenteric artery supplies blood to the distal transverse, descending, and sigmoid colon. Although diverticulosis is a left colonic condition, approximately 50% of diverticular bleeding originates from a diverticulum located proximal to the splenic flexure. The inferior mesenteric vein carries blood from the left side of the colon to the splenic vein.
Diverticula located on the right side may expose the larger portions of vasa rectae to injury because they have wider necks and larger domes compared to the typical left-sided colonic diverticulum.
A rich network of vessels from the superior, middle, and inferior hemorrhoidal vessels supplies the rectosigmoid junction and rectum. Colonic angiodysplasias are arteriovenous malformations located in the cecum and ascending colon. The symptoms of young patients with abdominal pain, rectal bleeding, diarrhea, and mucous discharge may be associated with IBD. Colonic angiodysplasias are an acquired lesion affecting elderly persons older than 60 years.

On the other hand, symptoms of elderly patients with abdominal pain, rectal bleeding, and diarrhea can be associated with ischemic colitis.
These lesions are composed of clusters of dilated vessels, mostly veins, in the colonic mucosa and submucosa. Stools streaked with blood, perianal pain, and blood drops on the toilet paper or in the toilet bowl may be associated with perianal pathology, such as anal fissure or hemorrhoidal bleeding. Colonic angiodysplasias are believed to occur as a result of chronic, intermittent, low-grade obstruction of submucosal veins as they penetrate the muscular layer of the colon. The physical examination must include careful inspection and examination of the oropharynx, nasopharynx, abdomen, perineum, and anal canal. The characteristic angiographic findings are clusters of small arteries during the arterial phase of the study, accumulation of contrast media in vascular tufts, early opacification, and persistent opacification due to the late emptying of the draining veins. Nasogastric aspirates usually correlate well with upper gastric hemorrhage proximal to the Treitz ligamentum; therefore, insert a nasogastric tube to confirm the presence or absence of blood in the stomach. If mesenteric angiography is performed at the time of active bleeding, extravasation of contrast media is visualized.
If necessary, perform gastric lavage with warm isotonic fluids to obtain bilious discharge from the nasogastric tube to exclude any upper GI bleeding beyond the pylorus.
Unlike diverticular bleeding, angiodysplasia tends to cause slow but repeated episodes of bleeding. Nasogastric tube aspirates can provide false-negative results in approximately 50% of cases if the aspirate contains no bile or if the bleeding is intermittent. These patients eventually need esophagogastroduodenoscopy (EGD) to obtain a more specific evaluation of the upper GI tract. Angiodysplasias can be easily recognized by colonoscopy as 1.5- to 2-mm red patches in the mucosa. Careful digital rectal examination, anoscopy, and rigid proctosigmoidoscopy should exclude an anorectal source of bleeding.
In up to 50% of patients with ulcerative colitis, mild-to-moderate lower GI bleeding occurs, and approximately 4% of patients with ulcerative colitis have massive hemorrhage. The frequency of bleeding in patients with Crohn’s disease is significantly more common with colonic involvement than with small bowel involvement alone.
Ischemic colitis, the most common form of ischemic injury to the digestive system, frequently involves the watershed areas, including the splenic flexure and the rectosigmoid junction. Colonic ischemia is a disease of the elderly population and is commonly observed after patients' sixth decade of life. Ischemic colitis is not associated with significant blood loss or hematochezia, although abdominal pain and bloody diarrhea are the main clinical manifestations. Colorectal carcinoma causes occult bleeding, and patients usually present with anemia and syncopal episode. The incidence of massive bleeding due to colorectal carcinoma varies from 5-20% in different series.
Postpolypectomy hemorrhage is reported to occur up to 1 month following colonoscopic resection. Benign anorectal disease (eg, hemorrhoids, anal fissures, anorectal fistulas) can cause intermittent rectal bleeding. The VA database review revealed that 11% of patients with lower GI bleeding had hemorrhage from anorectal disease. Patients who have rectal varices with portal hypertension may develop painless massive lower GI bleeding; therefore, examining the anorectum early in the workup is important.
Note that the discovery of benign anorectal disease does not exclude the possibility of more proximal bleeding from the lower GI tract.

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