A 79-year-old woman is brought to the emergency department by her daughter due to bloody stools. The patient has a 3-day history of occasionally passing blood with her stools but this morning she filled up the toilet bowl with bloody stools. She has not had another bowel movement since. She does not have any associated symptoms such as nausea, vomiting, or abdominal pain. Her past medical history includes mild dementia, hypertension, diet-controlled diabetes mellitus, and osteoarthritis. She does not smoke or drink alcohol. The patient takes a baby aspirin daily and nonsteroidal anti-inflammatory agents occasionally for hip pain. Her temperature is 36.7 C (98 F), heart rate is 89/min, blood pressure is 146/82 mm Hg, and respiratory rate is 16/min. She appears pale. Abdominal examination is unremarkable. Rectal examination reveals bright red blood in the rectal vault, without tenderness. Nasogastric aspirate shows copious amounts of bilious fluid. Laboratory results are as follows: She is started on intravenous fluids and blood work is ordered including blood type and cross-match. Which of the following is the most appropriate next step in the management of this patient?

Question

A 79-year-old woman is brought to the emergency department by her daughter due to bloody stools.  The patient has a 3-day history of occasionally passing blood with her stools but this morning she filled up the toilet bowl with bloody stools.  She has not had another bowel movement since.  She does not have any associated symptoms such as nausea, vomiting, or abdominal pain.  Her past medical history includes mild dementia, hypertension, diet-controlled diabetes mellitus, and osteoarthritis.  She does not smoke or drink alcohol.  The patient takes a baby aspirin daily and nonsteroidal anti-inflammatory agents occasionally for hip pain.  Her temperature is 36.7 C (98 F), heart rate is 89/min, blood pressure is 146/82 mm Hg, and respiratory rate is 16/min.  She appears pale.  Abdominal examination is unremarkable.  Rectal examination reveals bright red blood in the rectal vault, without tenderness.  Nasogastric aspirate shows copious amounts of bilious fluid.  Laboratory results are as follows:  She is started on intravenous fluids and blood work is ordered including blood type and cross-match.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf38_bdd8_8f63_dd166a4ed133_MD0005_00 Along with assessing hemodynamic stability, the first step in evaluating a gastrointestinal (GI) bleed is determining whether the source is in the upper or lower GI tract, with the ligament of Treitz separating the 2 sites. Bright red blood from the rectum (BRBPR) is nearly always due to a lower GI bleed (LGIB). Hematemesis and melena are more common in upper GI bleed (UGIB), although an UGIB can sometimes present with BRBPR if bleeding is particularly brisk. Hemodynamic compromise, orthostasis, and a blood urea nitrogen to creatinine (BUN/Cr) ratio >20:1 are suggestive of UGIB. A nasogastric lavage with aspiration of bile and absence of blood increases the likelihood of LGIB if the bleeding source is unclear; however, it can miss a distal UGIB. This patient with BRBPR is hemodynamically stable and has a normal BUN/Cr ratio as well as bilious fluid on nasogastric aspirate, consistent with LGIB. She received appropriate initial management (fluids, blood type and cross-match). Colonoscopy has diagnostic and potentially therapeutic abilities in LGIB and would be the next best step in management. If no bleeding source is found, esophagogastroduodenoscopy (EGD) is performed. In patients who are hemodynamically unstable or in whom UGIB is suspected, EGD should be considered first to exclude a brisk UGIB (Choice B). Diverticulosis is a common cause of brisk, painless hematochezia in an elderly patient and can readily be diagnosed by colonoscopy. Unlike diverticulosis, diverticulitis (which typically presents with left lower quadrant abdominal pain and low-grade fever, not BRBPR) would be a contraindication to colonoscopy due to the risk of perforation. (Choice C) A non-contrast CT scan of the abdomen can be helpful to evaluate for bleeding into the peritoneal cavity or retroperitoneum, but is not routinely used for evaluation of a GI hemorrhage. An arterial-phase contrast-enhanced CT with negative oral contrast can help to localize the source of bleeding, but this method is rarely utilized. (Choice D) Angiography can be considered in patients with BRBPR in whom EGD did not reveal a bleeding source and who continue to have persistent bleeding but are too hemodynamically unstable for a colonoscopy. If angiography is unsuccessful, other techniques (eg, colonoscopy if the patient is stable, tagged red blood cell scan, enteroscopy, surgery) are considered. (Choice E) Octreotide is used in the treatment of bleeding esophageal varices, but this is unlikely in this patient who has no history of cirrhosis and likely a lower GI source of the bleeding. Educational objective: Bright red blood per rectum suggests a lower gastrointestinal source of hemorrhage. After initial resuscitation with fluids and type and cross-match for possible transfusion, a colonoscopy is generally the next step in management for hemodynamically stable patients, as it can be both diagnostic and therapeutic. References: ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/16246674)

A 79-Year-Old Woman Is Brought to the Emergency Department by Her