DDSEP® 8 Quick Quiz

Question 1

Publish date: January 31, 2022

Q1. A 74-year-old female with a history of recurrent deep vein thrombosis on therapeutic warfarin presents to the emergency department with 1 hour of large volume bright red blood per rectum. Vital signs are as follows: heart rate, 110 bpm; blood pressure, 72/48 mm Hg. Examination reveals a pale, confused female in no acute distress, tachycardia, and a soft nontender abdomen without distension and no stigmata of liver disease. Lab results reveal international normalized ratio, 2.0; hemoglobin, 6.4 g/dL; and platelet count, 180,000/uL. Intravenous access is established, and crystalloid resuscitation is initiated. An urgent upper endoscopy reveals no blood or etiology for massive hematochezia. Despite resuscitation and transfusion of packed red blood cells, the patient continues to have massive hematochezia and remains confused and hypotensive requiring vasopressors and ICU support.

What is the next best step in management of this patient?

Emergent reversal of coagulopathy.

Rapid bowel prep and urgent colonoscopy.

Emergent unprepped colonoscopy.

Nuclear tagged RBC scan.

Emergent angiography.

Q1. Correct answer: E. Emergent angiography

Rationale
This patient presents with a massive lower GI hemorrhage. After a brisk upper GI bleed was ruled-out with esophagogastroduodenoscopy, the patient continued to hemorrhage and remained hemodynamically unstable. In the setting of a patient with ongoing massive lower GI bleeding who has been ruled out for an upper GI bleed (negative upper endoscopy) and who continues to have hemodynamic instability despite resuscitation, emergent angiography should be pursued in an effort localize and control bleeding.
Answer A is incorrect because an INR less than 2.5 does not require reversal prior to attempts at hemostasis. Answers B and C are incorrect because, given the patient's altered mental status and hemodynamic changes, she is unlikely to tolerate a bowel preparation and urgent colonoscopy. Also, there is no role for an unprepped colonoscopy in lower GI bleeding due to low yield and poor visualization. Answer D is incorrect because a nuclear-tagged red blood cell scan should be reserved for a patient who is hemodynamically stable.

Reference
Strate LL, Gralnek IM. Am J Gastroenterol. 2016 Apr;111(4):459-74.

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