A 70-year-old woman comes to the office for routine evaluation. The patient feels well and has had no shortness of breath, fatigue, dizziness, chest pain, unexpected weight changes, or bloody stools. Medical history is significant for constipation-predominant irritable bowel syndrome, hypertension, and diabetes mellitus. Temperature is 37.1 C (98.8 F), blood pressure is 138/86 mm Hg, pulse is 85/min, and respirations are 12/min. Mild conjunctival pallor is noted. Heart and lung sounds are unremarkable. The abdomen is soft, nontender, and nondistended. Rectal examination shows external hemorrhoids, and fecal occult blood testing is positive. Complete blood count reveals a hemoglobin level of 10.5 g/dL. Which of the following is the best next step in management of this patient?

Question

A 70-year-old woman comes to the office for routine evaluation.  The patient feels well and has had no shortness of breath, fatigue, dizziness, chest pain, unexpected weight changes, or bloody stools.  Medical history is significant for constipation-predominant irritable bowel syndrome, hypertension, and diabetes mellitus.  Temperature is 37.1 C (98.8 F), blood pressure is 138/86 mm Hg, pulse is 85/min, and respirations are 12/min.  Mild conjunctival pallor is noted.  Heart and lung sounds are unremarkable.  The abdomen is soft, nontender, and nondistended.  Rectal examination shows external hemorrhoids, and fecal occult blood testing is positive.  Complete blood count reveals a hemoglobin level of 10.5 g/dL.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This elderly patient has an occult gastrointestinal bleed (OGIB), characterized by unexplained iron deficiency anemia and/or positive fecal occult blood test (FOBT) in the absence of overt bleeding (eg, hematemesis, melena, hematochezia). Patients are usually asymptomatic. Pallor (eg, conjunctivae, oral mucosa) may be seen, and laboratory studies often demonstrate microcytic, hypochromic anemia (iron deficiency). Pathology may involve the colon (eg, malignancy, polyps), upper GI tract (eg, peptic ulcer), or, less commonly, the small bowel (eg, angiodysplasia). A positive FOBT suggests a colonic bleeding source but does not rule out proximal pathology and/or colonic lesions that are not actively bleeding. Initial workup of OGIB includes colonoscopy, particularly in the presence of a positive FOBT. Colon cancer is a likely cause in patients age >50. Upper endoscopy is also generally performed, particularly if the patient has upper GI symptoms, if iron deficiency anemia is present, or if colonoscopy does not reveal a bleeding source. Approximately 10% of patients with OGIB have simultaneous lesions in the upper GI tract and colon. If colonoscopy and upper endoscopy fail to identify a source of bleeding, small bowel evaluation can be performed with video capsule endoscopy or deep enteroscopy. (Choices A, D, and F) The presence of hemorrhoids does not preclude endoscopic evaluation in patients with an OGIB, as more serious pathology (eg, malignancy) may also be present. Anoscopy can be used to visualize internal hemorrhoids or other anorectal pathology, but cannot evaluate the colon for more proximal lesions. Medical (eg, topical hydrocortisone cream) and surgical management (eg, hemorrhoidectomy) may eventually be required in symptomatic patients, but are less of a priority than evaluation of an OGIB. (Choices C and E) Treatment of iron deficiency anemia includes iron supplementation and periodic assessment of hemoglobin to gauge therapeutic response. Although iron supplementation will likely be required in this patient, it does not identify the source of blood loss. Failure to evaluate may result in progression of the underlying disease. Educational objective: Occult gastrointestinal bleeding usually presents with unexplained iron deficiency anemia and/or a positive fecal occult blood test. Initial workup includes colonoscopy and upper endoscopy; small bowel evaluation (eg, video capsule endoscopy, deep enteroscopy) may be required if initial tests are unrevealing. The presence of hemorrhoids should not preclude endoscopic evaluation. References: Evaluation of occult gastrointestinal bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/23547576)

A 70-Year-Old Woman Comes to the Office for Routine Evaluation