NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Figure 8-38: Vascular ectasia of the colon: endoscopic appearance. Note the characteristic solitary flat red spot in the mucosa. (From Riddell R, Jain D. Lewin, Weinstein and Riddell’s Gastrointestinal Pathology and Its Clinical Implications , 2nd ed. Wolters Kluwer Health; 2014, Fig. 2-43A.)

Case 8.34 Persistent Bleeding with a Massive Lower Gastrointestinal Bleed You admit a 68-year-old with bright red bleeding per rectum. The presumptive diag- nosis is bleeding from a colonic diverticulum or vascular ectasia. After resuscitation and 2 units of blood, the patient stabilizes. Initial evaluation reveals no evidence of an upper GI bleed, no hemorrhoids, and no evidence of a coagulopathy. You plan to further evaluate the patient the next day if stable. That evening, the hematocrit is 35% after transfusion. The next morning, the patient begins to bleed profusely again with bright red blood per rectum. The heart rate has also risen to 130 beats per minute, and the BP is 100/60 mm Hg. A repeat hematocrit is 24%. You again resuscitate and administer 2 more units of packed RBCs. Although you had planned to perform a colonoscopy, it has not yet taken place. Q: What is the overall management plan at this point? A: The patient’s rebleeding is significant because of cardiovascular instability and a very low hematocrit despite previous transfusion . Medical management has failed, and sur- gery to stop the bleeding will most likely be necessary. Colonoscopic localization during active bleeding is difficult, less likely to demonstrate the bleeding cause, and associated with a significant risk of perforation due to poor visibility of the colon. SAMPLE