PR Bleeding

Question 1

An 88-year-old wan presents with a large amount of bright red PR bleeding. her BP is 70/50 mmHg and her HR is 120 BPM. She continues to bleed a lot in hospital. What is the appropriate management?

Answer 1

Impression
Patient is in hypovolaemic shock likely due to presentation of frank PR bleeding. Priorities are to stabilise and identify underlying aetiology for acute definitive treatment. Could be due to a number of pathologies;
Lower GI
- varices/haemarrhoids
- anal fissure
- diverticular bleed
- CRC
- iatrogenic (post-polypectomy bleed)
- vascular: angiodysplasia
Upper GI
- peptic ulcer
- oesophageal varices

Goals

• primary survey and concurrent stabilisation
• identify underlying aetiology
• ?explorative surgery, haemorrhage control

Question 2

PR Bleeding - Assessment

Answer 2

Assessment

• this is a surgical emergency given haemodynamic instability, would move patient to resus bay, call for senior help
• aim to stabilise patient before further assessment and management
• look through patient notes to identify underlying pathology

A - patent, maintaining
B - RR, Sats - supplemental
C - BP (invasive vs non-invasive), HR. 2xIVC - immediate fluid resus, replace like with like - bloods: FBC, UEC, VBG, group + xmatch, coags -> consider given PRBC and activate MTP. Reverse any anticoagulation as relevant
D: GCS
E: exposure, temperature

Question 3

PR Bleeding - History

Answer 3

History

• Sx: how long? how much blood? recent malena? abdo/anal pain? Any bowel/urinary symptoms,
• REDF: fevers, weight loss, night sweats
• PMHx: abdo surgery, malignancy, liver disease, autoimmune disease
• Fam Hx: cancer
• Medications: anticoagulation

Question 4

PR Bleeding - Examination

Answer 4

Examination

• General obs + vitals
• gastrointestinal examination: PR exam (pain, masses, haemorrhoid, polyps), masses, bowel sounds, focal tenderness, signs of chronic liver disease (varices)
• systems review

Question 5

PR Bleeding - Investigations

Answer 5

Investigations
- Key/diagnostic: once harm-dynamically stable, for CT angiography (abdo, pelvis)to identify source of bleeding +/e embilsation with IR. looking for extravasation of blood. Potentially for diagnostic/therapeutic colonoscopy

• Bedside: ECG, stool sample
• Bloods: FBC, LFT, UEC, iron studies
• Imaging: CT angiography, CT abdomen

Question 6

PR Bleeding - Management

Answer 6

Management

• surgical emergency given hypovolaemic shock.
• requires urgent stabilisation measures and involvement of gen surg + ICU

Definitive

• initial resuscitation as per ABCDE assessment
• consider reversal of anticoagulation (FFP, prothrombinex, vitamin K, protamine sulphate - heparin)
• Fluid resus - PRBC +/- MTP
• Surgical preparation -
• ?IR embolisation (angioembolisation, preferred over colonoscopy)

Supportive

• analgesia
• fluids
• antiemetics
• medications review