Question of the Week
For October 2, 2018
Your answer is correct.
Nuclear scintigraphyImmediate colonoscopy after rapid colonic lavageObservation Exploratory laparotomyAbdominal angiography
In a patient with massive lower gastrointestinal hemorrhage and ongoing bleeding whose upper esophagogastroduodenoscopy is negative, the next diagnostic and potentially therapeutic intervention after stabilization should be abdominal angiography.
In a patient with hemodynamic instability and ongoing lower gastrointestinal bleeding, urgent esophagogastroduodenoscopy (EGD) should be prioritized. Fifteen to twenty percent of patients have an upper source of hematochezia, and EGD is more robust and effective in identifying this source than an angiogram; it also carries less risk than an angiogram. If the EGD is negative and the severe bleeding continues after stabilization (as in this case), the next step is abdominal angiography, with possible transcatheter embolization. Angiography detects active bleeding at a rate of 0.5 to 1.0 mL per minute and can quickly localize the source and facilitate targeted intervention when the bleeding is rapid and the patient is deteriorating.
Although lower gastrointestinal bleeding can be managed endoscopically in some patients, the probability of successful therapeutic intervention with, and the safety of, urgent colonoscopy after rapid lavage in patients with severe hematochezia and clinical instability has not been determined. Diagnostic colonoscopy within 8 to 24 hours is recommended once the patient has been stabilized.
Although nuclear scintigraphy detects active bleeding at a rate of 0.1 mL per minute, it does not permit immediate therapeutic intervention. Scintigraphy may be mandated by the angiographer because a negative scintigraphy is associated with a high rate of negative angiography. In this patient, the ongoing hemodynamically significant bleeding mandates urgent therapy to stop the bleeding.
Exploratory laparotomy and blind, segmental colonic resection has been associated with a rebleeding rate as high as 75% and a mortality rate as high as 50%, so surgery should be avoided if possible.
Supportive care alone is inadequate when the bleeding is substantial and likely to persist without intervention.
Last reviewed Aug 2018. Last modified Jan 2018.