12-15-2007, 03:34 AM
A 68-year-old male presents to the emergency department with a complaint of bright red blood
per rectum. He has had several episodes of hematochezia, beginning on the evening before
presentation. He describes the bleeding as profuse and filling the toilet. On the morning of
presentation the patient felt light-headed and almost passed out while sitting on the toilet. He
has a past medical history of hypertension. He normally takes amlodipine for hypertension but
did not take it because of these symptoms. On physical examination the patient appears pale.
Blood pressure is 86/42, and heart rate is 134. He is unable to stand for orthostatic vital signs.
Abdominal examination reveals slight abdominal distention with hyperactive bowel sounds. He
has gross blood in the rectal vault. Initially, the patient undergoes volume resuscitation with
normal saline and receives 3 units of packed red blood cells. Blood pressure increases to
110/56 and heart rate decreases to 100 with these interventions. Initial hemoglobin is 7.2
mg/dL, and this rises to 9.8 mg /dL after transfusion. The patient is transferred to the medical
intensive care unit, where he subsequently undergoes a radionucleotide localization scan that
reveals a bleeding source in the right colon.The most appropriate next step in this patient's
management is determined to be selective mesenteric angiogram with coiling.
Despite appropriate intervention this patient continues to have bright red blood per rectum.
Which of the following is an indication to proceed with surgical intervention?
A. Inability to localize the bleeding source
B. Transfusion of more than 6 units of packed red blood cells in 24 h
C. Rebleeding after initial therapy
D. Failure of bleeding to stop with vasopressin therapy
E. Right-sided site of bleeding
per rectum. He has had several episodes of hematochezia, beginning on the evening before
presentation. He describes the bleeding as profuse and filling the toilet. On the morning of
presentation the patient felt light-headed and almost passed out while sitting on the toilet. He
has a past medical history of hypertension. He normally takes amlodipine for hypertension but
did not take it because of these symptoms. On physical examination the patient appears pale.
Blood pressure is 86/42, and heart rate is 134. He is unable to stand for orthostatic vital signs.
Abdominal examination reveals slight abdominal distention with hyperactive bowel sounds. He
has gross blood in the rectal vault. Initially, the patient undergoes volume resuscitation with
normal saline and receives 3 units of packed red blood cells. Blood pressure increases to
110/56 and heart rate decreases to 100 with these interventions. Initial hemoglobin is 7.2
mg/dL, and this rises to 9.8 mg /dL after transfusion. The patient is transferred to the medical
intensive care unit, where he subsequently undergoes a radionucleotide localization scan that
reveals a bleeding source in the right colon.The most appropriate next step in this patient's
management is determined to be selective mesenteric angiogram with coiling.
Despite appropriate intervention this patient continues to have bright red blood per rectum.
Which of the following is an indication to proceed with surgical intervention?
A. Inability to localize the bleeding source
B. Transfusion of more than 6 units of packed red blood cells in 24 h
C. Rebleeding after initial therapy
D. Failure of bleeding to stop with vasopressin therapy
E. Right-sided site of bleeding