Examkin

Question

Difficulty: HardGastroenterology and Hepatology

A 74-year-old man is brought to the emergency department after experiencing three episodes of massive, painless hematochezia over the past two hours. His medical history is significant for coronary artery disease, hypertension, and osteoarthritis, for which he takes daily aspirin and naproxen. On arrival, he appears pale and diaphoretic. His temperature is 36.8°C (98.2°F), blood pressure is 84/52 mm Hg, pulse is 122/min, and respirations are 20/min. Abdominal examination is unremarkable with no tenderness or guarding. Rectal examination reveals copious amounts of bright red blood. Arrange the following steps in the most appropriate sequence for the evaluation and management of this patient's acute presentation.

  1. 1Placement of two large-bore intravenous catheters and administration of isotonic crystalloids
  2. 2Esophagogastroduodenoscopy (EGD)
  3. 3Computed tomography angiography (CTA) of the abdomen and pelvis
  4. 4Catheter-directed mesenteric angiography with embolization

Answer

The correct sequence is: (1) Intravenous fluid resuscitation, (2) Esophagogastroduodenoscopy, (3) Computed tomography angiography, and (4) Mesenteric angiography with embolization.
In a patient presenting with massive hematochezia and hemorrhagic shock, the initial step is always hemodynamic resuscitation with intravenous fluids and blood products. Because a massive, rapid upper GI bleed can present with bright red blood per rectum, an esophagogastroduodenoscopy (EGD) must be the first diagnostic procedure performed. If the EGD is negative, the source is confirmed to be in the lower GI tract. In an unstable patient, there is no time for bowel preparation; thus, CT angiography is the test of choice to localize the bleeding, followed by therapeutic catheter-directed mesenteric angiography to embolize the bleeding vessel.

Step-by-Step Solution

1
Initiate aggressive fluid resuscitation via large-bore IV access.
Restoration of intravascular volume and hemodynamic stability.
The patient is in hypovolemic shock (hypotension, tachycardia) due to acute blood loss, making airway, breathing, and circulation the absolute first priority.
2
Perform an urgent Esophagogastroduodenoscopy (EGD).
Excludes or identifies an upper gastrointestinal source of bleeding.
Approximately 10-15% of patients presenting with massive hematochezia and hemodynamic instability actually have a brisk upper GI bleed, especially in the context of NSAID use. This must be ruled out before assuming a lower GI source.
3
Obtain a CT angiography (CTA) of the abdomen and pelvis.
Localizes the site of active lower GI bleeding.
If the EGD is negative and the patient continues to have massive bleeding or remains unstable, colonoscopy is contraindicated due to the inability to achieve adequate bowel preparation and the high risk of complications. CTA is rapid and highly sensitive for localizing active extravasation.
4
Proceed with catheter-directed mesenteric angiography.
Therapeutic embolization of the bleeding vessel.
Following localization via CTA, angiography is used to definitively treat the bleeding source in hemodynamically unstable patients who cannot undergo colonoscopy.

Key Concept

Management algorithm for massive hematochezia with hemodynamic instability
Rate this question

Topics

Gastroenterology and Hepatology

More questions from this topic