Hematochezia in a Patient With Diverticulosis

Case Study

A rapid response event was initiated by the bedside nurse after the patient had a large bloody bowel movement. On prompt arrival of the rapid response team, it was noted that the patient was a 72-year-old male with a known history of atrial fibrillation, for which he was anticoagulated with rivaroxaban. He had a history of diverticulosis as well. The patient was admitted to the hospital earlier in the day for evaluation of one episode of bright blood per rectum. At that time, he was found to have a hemoglobin of 6.7 gm/dL and had received one unit of packed red blood cells with an appropriate hematological response. Anticoagulation was held upon admission. A quick review of his chart indicated that the patient’s blood pressure had been slowly trending down, and per the registered nurse, the patient was starting to get more lethargic.

Vital Signs

Temperature: 98.2 °F, axillary
Blood Pressure: 86/50 mmHg
Pulse: 132 beats per min (bpm) – sinus rhythm on telemetry
Respiratory Rate: 22 breaths per min
Pulse Oximetry: 96% saturation on room air

Focused Physical Examination

A quick exam revealed an elderly Caucasian male who appeared pale and lethargic but could respond to questions appropriately. He had one 18 gauge peripheral IV line in his left antecubital fossa. He was cold to touch. His abdomen was soft, non-distended, and bowel sounds were hyperactive. The patient’s underpants were soaked in bright red blood. His pulmonary and cardiac examination was unremarkable.

Interventions

A cardiac monitor and pacer pads were attached to the patient. In addition, 1 L bolus of Ringer lactate was started immediately. Labs were drawn, including complete blood count (CBC), serum chemistries, liver tests, and coagulation studies. Two units of packed red cells were ordered stat. The patient’s blood pressure failed to improve with the first fluid bolus. Another 16-gauge IV line was placed, and the patient was given one unit of blood through a pressure bag, which improved systolic blood pressure to 90 s. Stat consult was obtained from gastroenterology, and a computed tomography (CT) angiogram of the abdomen was obtained. The patient was transferred to the intensive care unit (ICU) for further resuscitation, GI evaluation, and possible interventional radiology consultation.

Final Diagnosis

Acute frank lower gastrointestinal (GI) bleeding.

Acute Lower GI Bleed

Twenty percent of all cases of GI bleeding originate in the colon or rectum. Patients with a lower GI bleed usually present with sudden onset of hematochezia (maroon or red blood per rectum). Rarely, bleeding from the right side of the colon can present with melena. About 15% of the patients with presumed lower GI bleeding are bleeding from an upper GI source. Literature suggests that hematochezia associated with hemodynamic instability, orthostasis, and an elevated BUN/Cr ratio may indicate an upper GI bleeding source and warrant an upper GI endoscopy. The common causes of lower GI bleed are discussed in Table 52.1 .

Table 52.1

Common causes of lower gastrointestinal (GI) bleeds

Anatomic causes	Vascular causes
• Diverticulosis – the most common cause of lower GI bleeding. It also carries a high recurrence rate	• Hemorrhoids • Ischemia • Angiodysplasia • Post-polypectomy • Radiation-induced telangiectasia

Inflammatory causes	Neoplastic causes
• Inflammatory bowel disease • Infections • Ulcers – non-steroidal anti-inflammatory drugs enteropathy • Radiation-induced inflammation	• Polyps • Cancers