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Mrs Lincoln is a 62-year-old female who presents to the emergency department after developing bright red blood per rectum (BRBPR) that started last night. She has had a total of 8 episodes of BRBPR. She denies any abdominal pain, rectal pain, weight loss, or fevers. She does complain of fecal incontinence with these episodes. She has never had any previous episodes of GI bleeding. She has a history of diabetes mellitus type 2 and hyperlipidemia. Her home medications include metformin and simvastatin. She denies any tobacco or alcohol use. She had a colonoscopy 3 years ago that revealed diverticulosis without any other significant findings. On examination, she is awake and pleasant with a blood pressure of 136/74 mm Hg, heart rate of 84 bpm, respiratory rate of 16 breaths/min, and oxygen saturation of 98% on room air. She is afebrile. Her HEENT, cardiovascular, and respiratory examinations are all normal. Her abdomen is soft without any tenderness or distention. Bowel sounds are normal. Rectal examination reveals some red blood on the examination finger.

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Laboratory data show hemoglobin 12.5, hematocrit 37, and platelets 215,000. BUN is 15 and creatinine is 1.1. INR is 0.9. AST is 34 and ALT is 30.

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1. What is the most likely diagnosis?

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2. What is the initial goal of evaluation and patient care?

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3. What else is on the differential diagnosis?

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Answers

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This is a 62-year-old female with sudden onset of BRBPR that began last night. She has no other symptoms. A previous colonoscopy was negative for polyps or malignancy. Her vitals and physical examination show that she is hemodynamically stable. She has mild anemia. She requires further workup for these episodes of lower GI bleeding.

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  1. The most likely diagnosis is diverticular bleeding.

  2. The initial goals of her care revolve around monitoring volume status and anemia levels. She will require a nonurgent GI consult.

  3. The differential diagnosis includes malignancy, inflammatory bowel disease (IBD), hemorrhoids, and angiodysplasias.

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Lower GI Bleed

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Diagnosis

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Unlike upper GI bleeding, most patients with lower GI bleeding will show (at least temporarily) spontaneous resolution of the bleeding.

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Historical Clues
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A focused history should revolve around such questions as history of length of time and progression of bleeding, associated symptoms (such as abdominal pain, rectal pain, and weight loss), prior history of GI bleeding, and medication usage.

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Physical Clues
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Vital signs revealing hypotension, tachycardia, tachypnea, and hypoxia can help determine the degree of blood loss. Other physical examination findings to look for include dry mucus membranes, poor skin turgor, and evidence of hemorrhoids or rectal masses.

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Laboratory Clues
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The laboratory evaluation should focus on blood ...

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