Examkin

Question

Difficulty: MediumGastroenterology and Hepatology

A 72-year-old man with a history of hypertension and coronary artery disease is brought to the emergency department after passing three large, dark red, liquid bowel movements at home. On arrival, he is confused, pale, and diaphoretic. His temperature is 36.8°C (98.2°F), blood pressure is 82/52 mm Hg, and heart rate is 126/min. Abdominal examination reveals a soft and non-tender abdomen. Rectal examination shows copious amounts of maroon-colored stool.

Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient's acute presentation.

  1. 1Initiate aggressive intravenous fluid and blood product resuscitation
  2. 2Perform an esophagogastroduodenoscopy (EGD)
  3. 3Obtain computed tomography (CT) angiography of the abdomen and pelvis
  4. 4Perform percutaneous mesenteric angiography with selective embolization

Answer

The correct sequence for managing massive, hemodynamically unstable hematochezia is: 1) fluid resuscitation, 2) EGD to rule out upper GI bleed, 3) CT angiography to localize the lower GI bleed, and 4) mesenteric angiography for embolization.
The patient presents with hemorrhagic shock secondary to massive gastrointestinal bleeding. The most critical initial step in any unstable patient is resuscitation with intravenous fluids and blood products. Next, because 10-15% of patients with severe hematochezia and hemodynamic instability actually have a brisk upper gastrointestinal bleed (the blood acts as a cathartic, rapidly transiting the bowel), an esophagogastroduodenoscopy (EGD) must be performed to exclude an upper GI source. If the EGD is negative, the patient has a severe lower GI bleed. For hemodynamically unstable patients with ongoing lower GI bleeding, colonoscopy is inappropriate due to poor visibility and lack of bowel preparation. Instead, CT angiography should be obtained to rapidly localize the site of active extravasation. Once the bleeding site is identified, catheter-directed mesenteric angiography with embolization is the therapeutic intervention of choice to stop the bleeding.

Step-by-Step Solution

1
Recognize hemorrhagic shock and initiate resuscitation.
Patient receives intravenous crystalloids and packed red blood cells.
Airway, Breathing, and Circulation (ABCs) are the immediate priority in any unstable patient.
2
Exclude an upper gastrointestinal source of bleeding.
Patient undergoes EGD, which shows no active bleeding in the esophagus, stomach, or duodenum.
Massive upper GI bleeds can present with hematochezia due to rapid transit time. EGD is fast and can be both diagnostic and therapeutic.
3
Localize the source of the lower gastrointestinal bleed.
CT angiography is performed and identifies active extravasation in the ascending colon.
Colonoscopy is difficult and high-risk in unprepared bowel with active massive bleeding. CT angiography is fast and accurate for localizing bleeds greater than 0.3 mL/min in unstable patients.
4
Definitively control the bleeding.
Mesenteric angiography is performed with successful coil embolization of the bleeding vessel.
Once localized, catheter-directed embolization provides targeted hemostasis without the immediate risks of an emergency laparotomy.

Key Concept

The management of hemodynamically unstable lower gastrointestinal bleeding prioritizes initial resuscitation, exclusion of a massive upper GI source via EGD, radiographic localization using CT angiography, and endovascular hemostasis.
Estimated Time:1m 30s
Rate this question

Topics

Gastroenterology and Hepatology

More questions from this topic