Review Question - QID 203300

This patient presents with bright red blood per rectum (BRBPR) with hemodynamic compromise. The first diagnostic step is upper endoscopy to rule out a brisk upper GI bleed.

Lower GI bleeding is classified as GI bleeding distal to the ligament of Treitz. It often presents as hematochezia - bright red blood per rectum as compared to upper GI bleeds which typically present with hematemesis or melena. There are multiple causes of a lower GI bleed including hemorrhoids, diverticulosis, angiodysplasia, malignancy, inflammatory bowel disease, and infection conditions (Illustration B). Additionally, a very brisk upper GI bleed can present as hematochezia and a lower GI bleed (Illustration C). A brisk upper GI bleed is often caused by a peptic ulcer that has invaded an artery such as the gastroduodenal artery. This will often present with BRBPR and hemodynamic compromise. Any patient with lower GI bleeding and hemodynamic compromise must first receive an upper endoscopy to rule out a brisk upper GI bleed. Following upper GI endoscopy, further diagnostic procedure such as colonoscopy, Tc-TBC scan, and angiography can be performed (Illustration A).

Manning-Dimmitt et al. review the diagnosis and management of GI bleeding in adults. They state the clinical evaluation of GI bleeding depends on the hemodynamic status of the patient and the suspected source of the bleeding. Patients presenting with upper GI or massive lower GI bleeding, postural hypotension, or hemodynamic instability require inpatient stabilization and evaluation. The diagnostic tool of choice for all cases of upper GI bleeding is esophagogastroduodenoscopy; for acute lower GI bleeding, it is colonoscopy, or arteriography if the bleeding is too brisk.

Ramakrishnan and Salinas review the diagnosis and management of peptic ulcer disease. They state symptoms of peptic ulcer disease include epigastric discomfort (specifically, pain relieved by food intake or antacids and pain that causes awakening at night or that occurs between meals), loss of appetite, and weight loss. Surgery is indicated if complications develop or if the ulcer is unresponsive to medications. Perforation, brisk upper GI bleeds, and gastric outlet obstruction are rare but serious complications requiring surgical intervention.

Figure A demonstrates hematochezia. Illustration A depicts the treatment algorithm for lower GI bleeds. Illustration B depicts the causes of lower GI bleeds (excluding brisk upper GI bleed). Illustration C is an endoscopic image of a briskly bleeding peptic ulcer.

Incorrect Answers:
Answer 1: A technetium-99m–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.
Answer 2: Colonoscopy is typically the first diagnostic modality following upper endoscopy to rule out a brisk upper GI bleed.
Answer 3: Flexible sigmoidoscopy can be used in hemodynamically stable patients less than 40 years of age.
Answer 5: Angiography can be used to identify the source of a lower GI bleed in those patients where it is not identified on colonoscopy. However, upper endoscopy is always performed first in hemodynamically unstable patients.