Examkin

Question

Difficulty: HardGastrointestinal and Abdominal Surgery

A 65-year-old man is brought to the emergency department after experiencing three large episodes of painless, maroon-colored stool at home. He has a history of hypertension, hyperlipidemia, and osteoarthritis for which he takes naproxen daily. Upon arrival, he is lethargic. His temperature is 37.0°C (98.6°F), blood pressure is 85/50 mm Hg, and pulse is 122/min. Physical examination reveals pale conjunctivae and a non-tender, non-distended abdomen. Rectal examination shows gross maroon blood. Arrange the following interventions in the most appropriate chronological order for the optimal management of this patient, assuming the bleeding source remains elusive and persistent at each preceding diagnostic or therapeutic step.

  1. 1Initiate rapid intravenous fluid and blood product resuscitation
  2. 2Perform an esophagogastroduodenoscopy (EGD)
  3. 3Perform computed tomography (CT) angiography of the abdomen and pelvis
  4. 4Proceed with catheter-directed mesenteric angiography and embolization
  5. 5Perform an exploratory laparotomy and bowel resection

Answer

The correct sequential order is: 1) Initiate rapid intravenous fluid and blood product resuscitation, 2) Perform an esophagogastroduodenoscopy (EGD), 3) Perform computed tomography (CT) angiography of the abdomen and pelvis, 4) Proceed with catheter-directed mesenteric angiography and embolization, and 5) Perform an exploratory laparotomy and bowel resection.
The management of massive hematochezia in an unstable patient follows a strict algorithmic approach aimed at resuscitation, rapid localization, and least-invasive definitive control. Initial fluid and blood product resuscitation is universally the first step in hemorrhagic shock. Because 10-15% of massive lower GI presentations originate from an upper GI source (especially given this patient's NSAID use), EGD is the first diagnostic procedure. If EGD is negative, CTA is utilized as a rapid, non-invasive study to pinpoint active extravasation. Once localized, mesenteric angiography with selective embolization is attempted to stop the bleeding. Only if these less invasive modalities fail, or if the patient continues to exsanguinate despite maximal medical therapy, is surgical intervention (laparotomy with bowel resection) indicated as a life-saving salvage maneuver.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and begin resuscitation.
The patient is in hemorrhagic shock (hypotension, tachycardia). Intravenous fluids and blood products are given first.
Airway, Breathing, and Circulation (ABCs) must be secured before diagnostic testing.
2
Evaluate for a brisk upper gastrointestinal bleeding source.
An EGD is performed.
Up to 15% of patients with severe hematochezia actually have a massive upper GI bleed (e.g., peptic ulcer exacerbated by NSAIDs). EGD is diagnostic and potentially therapeutic.
3
Localize the lower gastrointestinal bleeding source.
A CT angiography is performed.
In unstable patients with active bleeding, CTA is the preferred initial imaging modality as it is fast, non-invasive, and helps interventional radiologists target the bleeding vessel.
4
Attempt endovascular therapeutic intervention.
Catheter-directed mesenteric angiography with embolization is performed.
This is a minimally invasive method to achieve hemostasis once the site is localized, avoiding the high morbidity of emergent surgery.
5
Proceed to definitive surgical control if all else fails.
Exploratory laparotomy and segmental or subtotal colectomy are performed.
Surgery is indicated for life-threatening hemorrhage that cannot be controlled endoscopically or angiographically.

Key Concept

Management algorithm for hemodynamically unstable massive lower gastrointestinal bleeding.
Rate this question

Topics

Gastrointestinal and Abdominal Surgery

More questions from this topic