What is the appropriate management for a patient with Ulcerative Colitis (UC) who reports a recent abortion on 05/02 and presents with persistent heavy bleeding, severe abdominal pain, and nausea?

From the Guidelines

For a patient with ulcerative colitis (UC) presenting with severe abdominal pain, nausea, and heavy bleeding after an abortion, a computed tomography angiography (CTA) should be performed to localize the bleeding site and guide further management. The patient's symptoms suggest a potential complication from the abortion, such as retained products of conception or uterine perforation, which may be exacerbated by the underlying UC 1. Given the patient's hemodynamic stability is not explicitly stated, it is crucial to prioritize imaging studies that can quickly identify the source of bleeding.

According to the WSES-AAST guidelines for managing inflammatory bowel disease in the emergency setting 1, computed tomography angiography should be performed in patients with ongoing bleeding who are hemodynamically stable after resuscitation. This recommendation is based on low-level evidence (QoE C), but it is the most relevant and recent guideline for this specific clinical scenario.

Key considerations in this patient's management include:

• Evaluating for potential complications from the abortion, such as retained products of conception or uterine perforation
• Assessing the severity of the UC and its potential contribution to the bleeding
• Monitoring for signs of hemodynamic instability and establishing IV access if necessary
• Considering urgent surgical intervention if the bleeding is life-threatening or if the patient is non-responsive to medical treatment 1

The use of upper and lower GI endoscopy as the initial diagnostic procedure may not be the most appropriate in this scenario, given the patient's recent abortion and potential for uterine or other gynecologic complications 1. However, these procedures may be considered if the CTA does not reveal a clear source of bleeding or if the patient's symptoms persist despite initial management.

From the Research

Patient Assessment and Scan Recommendations

The patient in question has a history of ulcerative colitis (UC) and has recently undergone an abortion, which is now complicated by severe abdominal pain, nausea, and significant bleeding. Given these symptoms, it's crucial to assess the patient thoroughly to determine the cause of the bleeding and pain.

• The patient's symptoms could be related to complications from the abortion, such as retained tissue, infection, or hemorrhage 2, 3.
• The presence of severe abdominal pain and nausea, in addition to bleeding, suggests the need for immediate evaluation to rule out serious complications like perforation or coagulopathy 2, 3.
• For a patient with UC, it's also important to consider the potential for exacerbation of the disease, which could contribute to the abdominal pain and bleeding 4.
• A comprehensive physical examination, including an abdominal exam, is essential in assessing the patient's condition and guiding further diagnostic steps 5.

Diagnostic Imaging

Given the acute presentation of the patient, imaging studies can play a critical role in diagnosing the cause of the symptoms.

• Abdominal computed tomographic (CT) scanning is recommended as the initial radiographic imaging study for UC patients with acute abdominal symptoms, including those with a history of recent abortion 4.
• Ultrasound can also be considered, especially for evaluating the uterus and potential complications related to the abortion, and it has the advantage of avoiding ionizing radiation 6.
• Magnetic resonance imaging (MRI) may have limited utility in the acute setting due to accessibility and examination duration but can be valuable in certain situations, such as evaluating specific complications or the extent of disease in UC 6.

Next Steps

The next steps should involve:

• Immediate assessment and stabilization of the patient, including addressing the severe bleeding and pain.
• Further diagnostic evaluation using appropriate imaging studies, such as CT or ultrasound, to determine the cause of the symptoms.
• Consideration of the patient's history of UC and the potential impact on the current situation, including the possibility of disease exacerbation.
• Development of a treatment plan based on the findings, which may involve medical therapy, potential intervention for complications related to the abortion, or management of UC exacerbation 2, 3, 4.