What is the most appropriate next diagnostic test for this patient?

Question of the Week

For October 2, 2018

A 70-year-old woman with a history of hypertension is admitted to the intensive care unit with hypotension and large-volume hematochezia. One month ago, she had a colonoscopy that was normal.

Her current physical examination reveals a heart rate of 120 beats per minute and a blood pressure of 92/65 mm Hg. Her abdomen is soft and nontender without palpable masses or organomegaly. A rectal examination reveals copious bright-red clots and active, ongoing bleeding.

Laboratory testing demonstrates a hemoglobin level of 6.0 g/dL (reference range, 12.0–16.0), a blood urea nitrogen level of 7 mg/dL (10–20), and a serum creatinine level of 0.7 mg/dL (0.6–1.1).

After she responds to initial fluid resuscitation and blood transfusion, urgent upper esophagogastroduodenoscopy is performed and is negative. However, brisk hematochezia continues. The patient remains tachycardic.

What is the most appropriate next diagnostic test for this patient?

Nuclear scintigraphy
Immediate colonoscopy after rapid colonic lavage
Observation
Exploratory laparotomy
Abdominal angiography

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.

Detailed Feedback

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.

Citations

Strate LL and Gralnek IM. Acg clinical guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol 2016 Apr; 111:459.   > View Abstract

ASGE Standards of Practice Committee. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014 Jun; 79:875.   > View Abstract

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