NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Figure 8-36: Contrast study of the bladder, showing a fistula between the colon and the bladder, a common occurrence. (From McKenney MG, Mangonon PC, Moylan JA, eds. Understanding Surgical Disease: The Miami Manual of Surgery . Philadelphia: Lippincott- Raven; 1998:141.)

Q: What is the initial evaluation and management plan? A: The patient’s signs and symptoms, including fatigue, tachycardia, dry mucous membranes, and pale conjunctiva, are suggestive of hypovolemia . Like all older patients, this patient is particularly susceptible to volume depletion because of the higher risk of heart disease. There- fore, it is necessary to insert two large-bore IV lines and 1–2 L of lactated Ringer solution , or 0.9 L normal saline, immediately to replace the fluid lost. Placement of an NG tube for lavage is warranted to evaluate and rule out an upper GI bleed. The patient requires placement on a monitor. Routine blood studies and a CXR are warranted. A coagulation evaluation is necessary to be certain that there is normal blood clotting, and blood for transfusion should be made available. Placement of a Foley catheter may be indicated to help evaluate the adequacy of resuscitation. If the lavage from the NG tube is positive for blood, an upper endoscopy is necessary. Anoscopy should also take place in the emergency department to examine for hemor- rhoids, bleeding rectal varices, or other anorectal pathology. SAMPLE