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Zorluk: ZorGastroenterology and Hepatology

An 81-year-old male resident of a skilled nursing facility is transported to the acute care unit following an episode of massive rectal bleeding. The nursing staff reports he passed several large clots of dark red blood and subsequently experienced presyncope. Upon arrival, he is pale, diaphoretic, and lethargic. Vital signs demonstrate a temperature of 36.1°C (97.0°F), a blood pressure of 78/42 mm Hg, and a pulse of 134/min. His medical history includes ischemic cardiomyopathy, chronic kidney disease, and advanced osteoarthritis, for which he takes daily naproxen and apixaban. Abdominal examination reveals normal bowel sounds and no guarding, rigidity, or focal tenderness. The rectal vault contains abundant fresh blood without palpable masses. Arrange the following interventions in the most appropriate sequential order for the management of this patient's acute presentation.

  1. 1Establish large-bore intravenous access and initiate aggressive crystalloid fluid resuscitation.
  2. 2Perform esophagogastroduodenoscopy (EGD) to evaluate for a proximal bleeding source.
  3. 3Obtain a computed tomography angiography (CTA) of the abdomen and pelvis.
  4. 4Perform catheter-directed mesenteric angiography with selective embolization.
  5. 5Proceed to surgical intervention with a subtotal colectomy.

Cevap

The correct sequence of management for hemodynamically unstable hematochezia is: 1) Intravenous fluid resuscitation, 2) Upper endoscopy (EGD), 3) Computed tomography angiography (CTA), 4) Catheter-directed angiography with embolization, and 5) Subtotal colectomy as a last resort.
In the management of massive, hemodynamically unstable hematochezia, initial treatment focuses strictly on ABCs and volume resuscitation. Because 10-15% of severe hematochezia originates from a briskly bleeding upper gastrointestinal source (e.g., peptic ulcer disease exacerbated by NSAIDs and anticoagulants, as seen in this patient), an EGD must be performed immediately after stabilization. If EGD is negative, the lower gastrointestinal tract is evaluated. Because the patient is unstable, colonoscopy is contraindicated. Instead, CTA is the preferred initial test to rapidly localize the bleeding vessel. If positive, CTA is immediately followed by catheter-directed angiography for targeted embolization. Surgery (subtotal colectomy) is reserved solely for refractory cases.

Adım Adım Çözüm

1
Initiate immediate hemodynamic resuscitation.
Restoration of intravascular volume and stabilization of perfusion.
The patient is presenting in hypovolemic shock (hypotension, marked tachycardia) secondary to massive acute blood loss.
2
Perform an urgent esophagogastroduodenoscopy (EGD).
Exclusion or identification of a rapidly bleeding upper gastrointestinal lesion (e.g., peptic ulcer).
Massive upper gastrointestinal bleeds can transit rapidly through the bowel, presenting as hematochezia rather than melena, and are a frequent cause of hemodynamic collapse.
3
Execute a computed tomography angiography (CTA).
Precise anatomic localization of the active lower gastrointestinal bleeding site.
CTA is a rapid, widely available, and non-invasive study that accurately identifies bleeding rates as low as 0.3 mL/min, directing subsequent targeted therapy.
4
Perform catheter-directed mesenteric angiography.
Therapeutic embolization of the identified bleeding vessel.
Once localized by CTA, conventional angiography allows for highly selective therapeutic embolization while minimizing contrast load and procedure time.
5
Execute a subtotal colectomy.
Definitive surgical control of hemorrhage.
Surgery carries high morbidity in the acute setting and is utilized exclusively as a salvage procedure when minimally invasive hemostatic techniques fail.

Anahtar Kavram

The diagnostic and therapeutic algorithm for hemodynamically unstable hematochezia emphasizes immediate resuscitation followed by ruling out an upper gastrointestinal bleed, then utilizing sequential radiologic localization and intervention prior to considering surgery.
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Gastroenterology and Hepatology

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