PR Bleeding

Question 1

A 68 year old man presents with light-headedness. He reports dark PR bleeding for the past 12 hours. he has been taking warfarin for atrial fibrillation. He has no other past medical history. His BP is 105/47, PR 103, 02 98%, RR 16, and T36.7. How would you assess and manage him?

Answer 1

Impression
Hypovolaemic shock secondary to a Lower GI bleed given frank PR bleeding, complicated by anticoagulant use
DDx
- Neoplasia: polyps, CRC, neuroendocrine tumour
- Vascular: Diverticular bleed, angiodysplasia
- Perianal: Haemorrhoids, anal fissure, trauma
- Infective: shigella, etc
- Upper GI bleed

Given the state of shock, my initial assessment and management would take A to E approach, calling for senior input early. Want to initiate resus replacing like-with-like, and appropriately dispositioning the patient to IR/gastro/gen surg depending on likely underlying aetiology

Question 2

PR Bleeding – Assessment

Answer 2

Assessment
- move to resus bay
- call for senior help
A - patent, maintaining - tube pending GCS
B - SP02/RR monitoring
C - HR/BP/ECG. 2xIVC, take initial bloods: VBG, FBC, G+H, coags, LFT, CRP/ESR. Start resuscitation with O- then matched blood. Reverse warfarin with vitamin K and prothrombinex (25-50u/kg) in acute setting, consider administration of FFP as well based on availability. Fluids and electrolyte balance, consider vasopressor support if ongoing HD instability
D - GCS
E / F / G

Dispositioning:
- gastro for urgent scope
o prokinetics (metoclopromide), bowel prep
- IR embolisation if not for colonoscopy
- gen surg: exploratory lap for resection of bleeding section (last resort treatment for non-remitting bleeding)

Question 3

PR Bleeding – History

Answer 3

History
- PC: onset, timing, progression, ?volume of bleeds, clarify colour - malena vs haematochezia vs frank.
- associated sx: fevers, weight loss, night sweats, diarrhoea, abdo pain (SOCRATES), recent illness
- sx of anaemia: fatigue, lethargy, pica, SOB, chest pain
- anticoagulant use: adherence, target INR, recent INR
PSHx: any recent colonoscopy/endoscopy +/- polypectomy, participate in bowel screening program?

Question 4

PR Bleeding – Examination

Answer 4

Examination
as per A to E
- General appearance + vitals; cachexia
- Evidence of chronic liver disease

Question 5

PR Bleeding – Investigations

Answer 5

Investigations

• bloods as per resus
• Imaging: CT Angiography, CT abdo for pathology
• Other: NGT aspirate for ?blood in Upper GI cause, Endoscopy - urgent gastro referral

Question 6

PR Bleeding – Management

Answer 6

Management
Supportive
- NBM
- Regularly monitor Hb every 4-8 hrs
- Withhold anticoagulation if possible (balance against risk of stroke/thrombosis withs CHadsVar vs HASBLED score - cardio consult for this
- Other: PPI infusion if suspected bleeding PUD, terlipressin if due to varicose

Definitive

• Endoscopy (Upper +/- lower depending on likely site of bleeding) for embolisation/stopping bleeding, may be difficult in significant bleeds
• IR embolisation
• GI surgery for resection if ongoing bleeding (last resort)