A 51-year-old man comes to the emergency department due to abdominal cramping, nausea, and bloody diarrhea. The patient reports having 2 episodes of large-volume, red- to maroon-colored, liquid stool over the past hour. He has also been feeling lightheaded but has had no vomiting, chest pain, or dyspnea. He sprained his ankle while playing racquetball 2 weeks ago and has been taking ibuprofen. He reports no chronic health issues and has never had similar symptoms in the past. Screening colonoscopy a year ago revealed scattered diverticulosis but was otherwise unremarkable. He smokes a pack of cigarettes daily and drinks a 6-pack of beer every week. Temperature is 37.3 C (99.1 F), pulse is 112/min, and blood pressure is 116/70 mm Hg while supine and 90/60 mm Hg while standing. The patient appears anxious and diaphoretic. Cardiopulmonary examination is normal with the exception of tachycardia. The abdomen is nondistended and soft with mild generalized tenderness. There is no guarding or rebound tenderness, and bowel sounds are hyperactive. Rectal examination reveals maroon-colored stool. Fingerstick hemoglobin is 12 g/dL. Blood samples for cell counts, serum chemistry, and type and crossmatch are obtained. Intravenous access is established and intravenous fluids are administered. Which of the following is the best next step in management of this patient?

Question

A 51-year-old man comes to the emergency department due to abdominal cramping, nausea, and bloody diarrhea.  The patient reports having 2 episodes of large-volume, red- to maroon-colored, liquid stool over the past hour.  He has also been feeling lightheaded but has had no vomiting, chest pain, or dyspnea.  He sprained his ankle while playing racquetball 2 weeks ago and has been taking ibuprofen.  He reports no chronic health issues and has never had similar symptoms in the past.  Screening colonoscopy a year ago revealed scattered diverticulosis but was otherwise unremarkable.  He smokes a pack of cigarettes daily and drinks a 6-pack of beer every week.  Temperature is 37.3 C (99.1 F), pulse is 112/min, and blood pressure is 116/70 mm Hg while supine and 90/60 mm Hg while standing.  The patient appears anxious and diaphoretic.  Cardiopulmonary examination is normal with the exception of tachycardia.  The abdomen is nondistended and soft with mild generalized tenderness.  There is no guarding or rebound tenderness, and bowel sounds are hyperactive.  Rectal examination reveals maroon-colored stool.  Fingerstick hemoglobin is 12 g/dL.  Blood samples for cell counts, serum chemistry, and type and crossmatch are obtained.  Intravenous access is established and intravenous fluids are administered.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient presents with hematochezia (bright red or maroon-colored stool), which is most commonly due to bleeding from the lower gastrointestinal (GI) tract (eg, diverticulosis, hemorrhoids). However, rapid, large-volume bleeding from an upper GI source (eg, peptic ulcer) can lead to hematochezia rather than the more classic melena (black and tarry stool) typically associated with an upper GI bleed; up to 15% of cases of hematochezia are due to upper GI bleeding. In patients with hematochezia and hemodynamic instability, it should be initially assumed that there is an upper GI source of bleeding if there is no strong suggestion of a lower GI source (eg, passage of large clots, known recent diverticular bleed). This patient has orthostatic hypotension as well as risk factors for upper GI bleeding (eg, ibuprofen use); therefore, following initial volume resuscitation, esophagogastroduodenoscopy (EGD) for identification and treatment (eg, hemostatic clipping) of a suspected upper GI source is most appropriate. If EGD fails to identify a source, colonoscopy should then be pursued. For patients who remain hemodynamically unstable despite initial volume resuscitation, interventional radiology procedures (eg, angiography with embolization) are often the best alternative to EGD. (Choices A and D) Both abdominal CT angiography and radionuclide bleeding scanning (using tagged red blood cells) can be helpful in localizing active GI bleeding. However, because these tests are only diagnostic and not therapeutic, EGD is preferred. (Choice B) Initial intervention with colonoscopy is appropriate in patients with hemodynamically stable hematochezia or strong suggestion of a lower GI source. However, EGD is the most appropriate initial intervention in patients with hemodynamic instability and reasonable suspicion for an upper GI source of bleeding. (Choice E) Wireless video capsule endoscopy makes use of a capsule that is swallowed by the patient and transmits images as it passes through the bowel. It is typically reserved for when both EGD and colonoscopy fail to localize bleeding and the source is thought to be in the small intestine. Educational objective: Although hematochezia is most commonly associated with lower gastrointestinal (GI) bleeding, large-volume, upper GI bleeding can also present with hematochezia. Patients with hematochezia and hemodynamic instability (eg, orthostatic hypotension) should generally be assumed to have an upper GI source of bleeding. Following initial volume resuscitation, they should undergo initial evaluation with esophagogastroduodenoscopy. References: A prospective characterization of upper gastrointestinal hemorrhage presenting with hematochezia. (http://www.ncbi.nlm.nih.gov/pubmed/9040197)

A 51-Year-Old Man Comes to the Emergency Department Due to Abdominal