Review Question - QID 103300

This patient with bright red blood per rectum (BRBPR) and hemodynamic instability likely has brisk bleeding from an upper GI source. The most appropriate initial step in management after volume resuscitation is upper endoscopy to evaluate for bleeding in the upper GI tract.

Gastrointestinal bleeding is distinguished by position relative to the ligament of Treitz. Upper GI bleeding is proximal to the ligament Treitz by definition while lower GI Bleeding occurs distally. BRBPR or hematochezia is typically due to lower GI bleeding, but may be due to a brisk upper GI bleed. Factors favoring upper GI bleeding in patients with hemtaochezia or BRBPR include hemodynamic instability, elevated BUN:creatinine ration (usually >30:1), or history of peptic ulcer disease. This patient with a history suggestive of preceding peptic ulcer disease and hemodynamic instability has a presentation concerning for a brisk upper GI bleed. The first step in management for patients with hematochezia or BRBPR and hemodynamic instability is the placement of at least two large-bore intravenous catheters followed by volume resuscitation. The next most appropriate diagnostic step in this case is upper endoscopy to evaluate for upper GI bleeding.

Kamboj et. al review the etiologies, diagnosis and management. They note that up to 15% of patients with hematochezia or BRBPR actually have brisk upper GI bleeding. They recommend upper endoscopy as the initial step in management after volume resuscitation for patients with hemodynamic instability.

Figure A demonstrates a bowel movement containing bright red blood and hematochezia (dark, maroon colored stools).

Illustration A is an endoscopic image of a briskly bleeding peptic ulcer, most likely from an arterial source.

Incorrect Answers:
Answer 1: Angiography may be utilized if upper endoscopy does not reveal a source of bleeding, and that patient continues to bleed. Upper endoscopy is the more appropriate initial diagnostic step in this patient.

Answer 2: Colonoscopy is typically utilized after resuscitation and upper endoscopy for hemodynamically unstable patients if bleeding has resolved. Upper endoscopy is the more appropriate initial diagnostic step in this patient.

Answer 3: Flexible sigmoidoscopy is an alternative to colonoscopy that provides a less extensive visualization of the lower GI tract. Upper endoscopy is the more appropriate initial diagnostic step in this patient.

Answer 4: A tagged red blood cell scan is a nuclear study best suited for identifying slow-bleeding lower GI sources with rates of 0.1 to 0.4 mL per hour. However, upper endoscopy is always performed first in hemodynamically unstable patients that are concerning for a brisk upper Gi bleed

Bullet Summary:
For patients with hematochezia or bright red blood per rectum that present with with hemodynamic instability, upper endoscopy is the most appropriate initial diagnostic step after initiation of volume resuscitation.