Review Question - QID 202631

This patient is suffering from a GI bleed, as evidenced by her hematochezia, or bright red blood per rectum. A patient presenting with a GI bleed should undergo a type and cross to allow for prompt blood transfusion if it becomes necessary.

The initial management of a patient with a GI bleed is as follows:
1. Assess severity: tachycardia 10% volume loss, orthostatic hypotension 20% volume loss, shock 30% volume loss.
2. Resuscitation: place 2 large-bore IV lines and give NS or LR
3. Transfuse: type and cross, transfuse 2-8 units
4. Reverse coagulopathy: FFP and vitamin K to normalize PT
5. Triage: consider ICU if unstable

Once this initial management has been completed, the patient may undergo diagnostic studies such as esophagogastroduodenoscopy (EGD) or colonoscopy. EGD is indicated for an upper GI bleed (characterized by hematemesis and melena) while colonoscopy is indicated for a lower GI bleed (characterized by hematochezia). Therefore, a colonoscopy would be indicated in this patient.

Manning-Dimmitt et al. review the evaluation and treatment of GI bleeds. "The diagnostic tool of choice for all cases of upper gastrointestinal bleeding is esophagogastroduodenoscopy; for acute lower gastrointestinal bleeding, it is colonoscopy, or arteriography if the bleeding is too brisk. When bleeding cannot be identified and controlled, intraoperative enteroscopy or arteriography may help localize the bleeding source, facilitating segmental resection of the bowel."

Illustration A helps differentiate upper and lower sources of GI bleed.

Incorrect answers:
Answer 1: EGD is indicated for evaluation of suspected upper GI bleed. This patient is more likely to have a lower GI bleed, and should undergo type and cross first anyway.
Answer 2: Colonoscopy is indicated for evaluation of suspected lower GI bleed. A colonoscopy would be indicated in this patient after she has been appropriately stabilized and a type and cross obtained.
Answer 3: Non-contrast abdominal CT can be used to visualize bleeding in the peritoneal cavity or retroperitoneum. Abdominal CT with contrast can be used to localize a source of bleeding in some circumstances, but EGD or colonoscopy are more appropriate modalities for the evaluation of a suspected GI bleed.
Answer 4: If this patient were on warfarin, or thought to be anticoagulated for some other reason, reversal would be the next appropriate step after obtaining a type and cross.