65 years old white female is brought to the ER with a one day history of passing bright red blood with bowel movements, She has had three episodes with moderate amount of fresh blood mixed with stools, with no anal pain, Her stools are soft in consistency and there is no history of fissures or hemorrhoids in the past, She felt weak and light headed. There was no history of nausea, vomiting or abdominal pain. She denied any hematemesis, melena, diarrhea, constipation, jaundice or weight loss, Her past medical history is significant for type I] diabetes mellitus, hypertension and hyperlipidemia, She has never had a colonoscopy in the past, She has no allergies, Her medications include glyburide, simvastatin and lisinopril, The patient does not smoke ar consume alcohol, Her mother died of colon cancer at the age of 60 years. Rest of the review of systems is unremarkable,
How would you approach this patient?
This is a patient with hematochezia, who is hemodynamically unstable as is obvious from the hypotension, orthostasis and tachycardia. The initial approach should be to take the general resuscitative measures, a delay in which might be life threatening. Simultaneously, think of a differential diagnosis and order the relevant tests to rule in and rule out the disease process and its eticolagy. Remember you always need a thorough focused physical examination before establishing 4 diagnasis,
Order No. 1:
I¥ access, stat - 2 large (18 G) IV bore needles Start I fluids: Normal Saline, bolus
Make HPO
Continuous BP, HR monitoring
Pulse oximetry, stat
Results for Order No. 1: BP - 100/70 rim Hg; HR- 124/'min Oxygen Saturation is 9796 an room air
Order physical exam:
General appearance
HEENT “Neck
Examination of C¥S
Examination of lungs
Examination of Abdomen
Examination of Rectum
FOBT (not required if u see a fresh bleeding} Extremities
Skin
Results of Physical Examination:
General appearance: Pale looking, anxious female. HEENT: Pale conjunctiva, anicteric sclera, dry mucous membranes; no J¥O. No palpable lymph nodes, Lungs are clear to auscultation and percussion bilaterally, Cardiovascular: Tachycardic, S51 52 normal, no murmurs, rub or gallop. Abdomen is soft, non tender, no rigidity, rebound or guarding; bowel sounds are normal, no organomegaly or free fluid. Rectal: Normal sphincter tone, no hemorrhoids or fissures, blood in rectum. Extremities: no edema, clubbing or cyanosis, no calf tenderness, peripheral pulses feeble. Rest of the exam is unremarkable,
Order No.2?
CBC with differential, stat
BMIP, stat
LFTs, stat
PT/aPTT, stat
EKG, 12 lead, stat
Blood Typing and Cross-match - in preparation for transfusion Nasogastric tube placement and aspiration
Anoscopy, stat
Discontinue her glyburide, simvastatin and lisinopril
Results for Order No. ?:
BP - 100/70 mm Hg; HR- 124/min
CBC: Hgb -7.5 g/dl, Hct- 22.5 9%, WBC - 12,000/ uL, Platelet - 450,000/mm?*, normal differential count
BMP: BUN - 25, Creatinine -1.0, Sodium -135 meg/L, Potassium - 3.7 meg/L, Chloride -104 meg/L, Bicarbonate - 25 meg/L
LFT: Total bilirubin - 1.0 mg %, Direct bilirubin - 0.4 mg %, ALT - 31 IU/L, AST - 30 IUL, Alkaline phosphatase - 110 IU/L
PT=17 sec, INR=1.60; aPTT=39 sec, control=35 sec
EKG shows sinus tachycardia without evidence of ischemia or infarction
Nasagastric aspirate - bilious with no blood
Anoscopy - no anal fissures; no external or internal hemorrhoids; no ulcerations in distal part of rectum
Order No. 3:
Continue NPO
Stop I’v NS
Start packed RBC transfusion - 3 Units
4 Units fresh frozen plasma (FFP)
H and H every 6 hours
PT after FFP transfusion
Continuous BP monitoring
Discontinue NG tube
Complete bed rest
Apply pneumatic compressions for DYVT prophylaxis
Accuchecks every 6 hours (use regular insulin as needed, based on blood sugar levels) Admit in ICU
Examine the patient 6 hours later: order interim history and focused physical exam (rake sure you listen lungs as they may develop fluid overload with all the [IV infusions).
Results for Order No. 3:
BP - 110/70 mm; HR- 100,/'min
After 3 Units of PRBC and 4 Units FFP Hgb-10.5 g/dl}; Het-30%
PT=14.5 sec, INR=1,45
Patient feels better; exam looks fine
Order No. 4:
Gastroenterology consult for colonoscopy (Reason: 65 yr old with Hematochezia, no prior Colonoscopy; Please evaluate for the source of bleeding}.
Continue NPO
Restart IV NS, continuous (if the lungs are clear}
H and H every 6 hours
Start bowel preparation for colonoscopy - 4 liters of polyethylene glycol (Golytely, Colyte}) given over two hours
Continuous BP monitoring
Call me when the lab results available
Results for Order No. 4:
Colonoscopy - Multiple diverticuli in sigmoid and descending colon, Biopsy taken Hgb-10.2 g/dl} Het- 30.6 96
BP - 120/80; HR- 90min
Order No. 5
Discontinue NPO
Stop Iv NS
Start clears and advances to high fiber diet as tolerated H and H every 6 hours
Continue BP monitoring
Results of order No. 5:
Patient is tolerating low roughage diet
Hgb-10.0 g/dl} Het- 30.0 96
BP - 129/80: HR- 74/min
Biopsy is positive for diverticulosis, no inflammation or ulceration; no malignant cells
Order No.6
Discharge the patient home after overnight watch
High fiber diet
Restart her home medications
D/C DYT prophylaxis
Avoid nuts and fruits with seeds (No option in software}
Follaw up appointment in one week with repeat Hqb and hematocrit,
Discussion:
Differential Diagnosis: LG] bleed by definition is bleeding distal to the ligament of Treitz, Most patients with bright red blood per rectum of hematochezia have 4 LG] bleed, but about 1095 are the result of 4 brisk UGI bleed, Thus patients with hematochezia should have a nasogastric tube lavage to exclude an upper gastrointestinal hemorrhage, An EGD instead of the usual colonoscopy may be needed to establish the cause af hematochezia in case the nasogastric aspirate shows blood,
The most common causes are diverticulosis, angiadysplasia, polyps and colon cancer in 4 patient above 65 years. All these conditions are painless, except colon cancer, which sometimes may be associated with abdominal pain. This patient is at a high risk of colon cancer because of a positive family history, Another important cause to consider in this patient is ischemic colitis since she has multiple risk factors for vascular disease, However, ischemic colitis is most oaften associated with abdominal pain. Also remember, that diverticular bleed usually do mot occur in the presence of diverticulitis. GQther less common causes include inflammatory bowel disease (ulcerative colitis, crohn’s disease), vasculitis (Polyarteritis nodosa, Wegqner’s granulomatosis), radiation colitis, and infectious colitis (Ecoli, salmonella, CMY 4,
hanagement:
Hemodynamic stabilization is more important before a colonoscopy. Hemodynamically unstable patients should be admitted in the intensive care unit, Presence of shock, orthostatic hypotension, 4a 696 drop in hematocrit or blood transfusion requirement of two or more units suggests hemodynamic instability.
2, All patients with GI bleeding should have two large bore (18 G or larger) peripheral I’v lines.
Patient should be resuscitated with blood transfusions to keep a hematocrit greater than 30%, If coagulopathy is present, transfusion with FFP and administration of Vitamin Kk is needed to keep the INR
below 1.5, Platelet transfusions may be needed for platelet counts of less than 50,000/ mm?.
4, Calcium levels should be monitored as multiple transfusions may lead to hypocalcimia requiring specific therapy.
§. Nasogastric tube lavage should be done. If it shows no blood of has copious bile then the investigation af choice once the patient is stabilized, is colonoscopy, Colonoscopy can localize the site of bleeding, allow tissue biopsies and therapeutic interventions like injection sclerotherapy and electrocautery, However, 4 good bowel preparation is needed for good visualization of the colon, If nasogastric aspirate shows blood then an EGD is recommended as the initial investigation of choice. If EGD is negative, then go ahead with colonoscopy,
What if the colonoscopy is normal but the patient continues to have hematochezia?
Order a tagged red blood cell scan (radionuclide imaging study} — Radionuclide scanning is a highly sensitive technique that can detect bleeding occurring at arate of 0.1 to 0.5 mL/minute. However, it cannot localize the site of bleeding and requires presence of active bleeding at the time of the test. If the tagged RBC scan is positive, one must proceed with angiography.
Angiography detects blood loss as low as 0,5 mL/minute, The procedure is 100 percent specific and is performed to accurately localize the site of bleeding, especially if surgical management is needed. It also permits control of bleeding using vasopressin infusion or embolization via the catheter. However, it is an invasive procedure and needs to be performed during active bleeding.
*Remember that angiography is reserved for patients in whom colonoscopy cannot localize the site of bleeding or is not feasible,
When should I get surgery consult?
4 surgical consultation is needed for continued severe bleeding with high transfusion requirements. A blind surgery performed without localizing the site of bleeding carries a higher risk of rebleeding. Hence, if feasible a tagged RBC scan and angiography should be done before proceeding for surgery.
Final Diagnosis: Lower gastrointestinal hemorrhage, secondary to diverticulosis,
Location: Emergency Room ¥Yitals: BP: 80/50 mmHg; HR: 40min; RR: 24min; Temp: 98.4F C.C: Lightheadedness