PR bleeding

Question 1

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

Answer 1

Impression
With a BP of 70/50 I am concerned about hypovolaemic shock secondary to Frank PR bleeding. This presentation demands urgent escalation for senior help as well as assessment and resuscitation using an ABCDE approach.

Important to concurrently consider the differential causes of this presentation. Given the bright red PR bleeding, this is likely a lower GI source of bleeding. Notably, in an 88 year old woman I am concerned about bleeding CRC as the cause. Other DDx to consider include;

• bleeding haemarhoids
• diverticular bleed
• infective (unlikely large frank PR bleed)
• anal fissure
• IBD (ulcerative colitis)
• neoplasia (polyps)
• angiodysplasia/telangiectasia

Question 2

PR bleeding - Assessment

Answer 2

Assessment
Given patient is HD unstable, would call for senior help, move to ED resus bay, assemble resus team and begin A to E assessment

A - patent, maintaining, adjuncts pending GCS (?tube)
B - RR, SP02, supplemental as required
C - 2xIVC, VBG, FBC, Coags. Group + xmatch, start fluid resus, activate MTP and begin replacement under senior guidance, want FFP, PRC and Cryo in appropriate ratios. start any relevant anticoagulation reversal (dabigatran = praxibind, protamine sulphate, prothrumbinex, Vit K, etc).
D - GCS, ?intubation
E - temp, as per
F - as per
G - as per

Question 3

PR bleeding - History/Exam

Answer 3

History
MIST AMPLE

• anticoagulation
• medical co-morbidities
• look up patient notes for any recent investigational findings
• associated symptoms: pain, constipation, pain, tenesmus, PMHx of abdo pathology

Exam

• general assessment
• vitals
• abdominal exam
• Rectal examination:

Question 4

PR bleeding - Investigations

Answer 4

Investigations
Once stabilised, consider further investigations;
- colonoscopy
- CT abdo, CT abdo arterial phase/angiography to identify source of bleeding

Bloods: serial FBC, coags, G+xmatch

Question 5

PR Bleeding - Management

Answer 5

Management
Initial management as per ABCDE assessment
Once stabilised, look to definitively manage

Supportive

• retrieval to tertiary centre if required
• ICU admission
• documentation
• VTE prophylaxis

Definitive

• IR embolisation
• colonoscopy and therapeutic coiling/tumour removal

CRC
- MDT for ongoing treatment regimen (chemo +/- surgery +/- radiation adjuvant/neoadjuvant