Lower Gastrointestinal Bleed

You are the general surgery CT1 asked to see a 75-year old lady who has had multiple witnessed episodes of fresh bloody diarrhoea and clots. She is known to have atrial fibrillation and takes warfarin. When you see her, the bleeding has stopped but she is complaining of generalised abdominal pain. How would you proceed? 

Example answer introduction

I suspect that this lady may have ischaemic colitis due to her history of atrial fibrillation. However, I would keep a wide differential of diverticulitis, angiodysplasia, colonic carcinoma and anorectal disease. I would initially stabilise the patient and then take a focused history, perform a focused examination and request the relevant investigations depending on my clinical suspicions. I would then initiate treatment and escalate to my registrar for senior review. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications - anticoagulants, antiplatelets

  • Past medical history – previous bowel surgery

  • Last meal

  • Events leading up to this point – estimated blood loss, nature of pain, nausea and vomiting, diarrhoea, constipation, weight loss, PR bleeding

Abdominal examination

  • Inspect – distention, surgical/traumatic scars, discolouration, hernia

  • Auscultate – decrease or absent bowel sounds

  • Palpate – Tenderness, guarding, rebound tenderness, peritonism

  • Percussion – Resonant

  • Digital rectal examination – melena/fresh blood, masses, external genitalia 

Example questions to progress the station

Q1 What further investigations might you order?

I would then request the following investigations: 

 

  • Urine dip – looking for blood, leukocytes, nitrites, glucose, ketones

  • Stool culture

  • Abdominal x-ray – Evidence of bowel obstruction

  • Erect chest x-ray – Air under diaphragm signifying perforated viscus. 

  • Colonoscopy after discussion with registrar. 

 

Q2 She is exquisitely tender in the left lower quadrant, with rebound tenderness and peritonism. She has temperature of 38.0, WCC 16, CRP 90 and a mild AKI. The concerned A&E consultant has already arranged a CT abdomen and pelvis which has shown an ischaemic section of large bowel, how would you proceed?

Initial management

I would instigate initial treatment and inform the surgical registrar immediately as she will need to go to theatre for a laparotomy + colectomy. 

 

  • IV antibiotics according to local protocol 

  • Analgesia according to the WHO pain ladder

  • IV crystalloids to maintain urine output of 0.5ml/kg/hr 

  • Keep nil-by-mouth

  • Hold antiplatelet therapy, reverse warfarin with vitamin K if high INR and active bleeding

  • Prep for theatre – P-POSSUM score. Inform emergency theatre, anaesthetist on call. 

  • VTE Prophylaxis

  • Keep patient and any relatives informed

  • Document, document, document!!!

Escalation
I would inform the Registrar to review the patient in a timely manner, to ensure my diagnosis and management plan were correct.
It may be expected of you to put the patient on the emergency list so close communication with theatre staff and anaesthetics may be necessary. 
Similar to previous cases this patient may be extremely unwell. Discussion critical care should be done in a. timely fashion in this case. 
Useful Resources

ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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