From the Guidelines
I strongly recommend immediate transfer of the patient to a tertiary center with interventional radiology capabilities for CT angiography and potential embolization or surgical intervention, as the patient's condition is critical and requires urgent attention.
Identification
The patient is a 68-year-old male, admitted to our medical unit three hours ago with severe lower left quadrant abdominal pain, bright red rectal bleeding, and hypotension.
Situation
The patient is currently hemodynamically unstable with ongoing rectal bleeding. His vital signs show BP 90/60 mmHg, HR 115 bpm, RR 22, temp 38.2°C, and oxygen saturation 94% on room air.
Background
The patient has a history of diverticular disease, hypertension, and type 2 diabetes. He reports experiencing intermittent abdominal pain for three days that suddenly worsened this morning, followed by significant rectal bleeding. Initial lab results show hemoglobin of 8.2 g/dL (baseline 13.5 g/dL), WBC 15,000/μL, and elevated CRP.
Assessment
The patient is experiencing an acute hemorrhagic episode of diverticulitis with significant blood loss requiring urgent intervention. While abdominal ultrasound shows thickened bowel wall in the sigmoid region, we cannot perform CT angiography at our facility to precisely locate the bleeding source.
Recommendation
I recommend immediate resuscitation with two large-bore IVs, crystalloid fluids, and blood transfusion (2 units PRBCs) as suggested by 1. Start broad-spectrum antibiotics with piperacillin-tazobactam 4.5g IV q8h and metronidazole 500mg IV q8h, as recommended by 1 and 1. The patient requires urgent transfer to a tertiary center with interventional radiology capabilities for CT angiography and potential embolization or surgical intervention. While awaiting transfer, maintain NPO status, continue IV fluids, monitor vital signs every 15 minutes, and prepare for possible emergency surgery if bleeding worsens or the patient decompensates further. This approach is supported by the guidelines for the management of acute colonic diverticulitis, which emphasize the importance of prompt and effective treatment to prevent complications and improve outcomes 1.
From the Research
ISBAR Scenario: Hemorrhagic Episode of Diverticulitis
- I: Identify the patient: a patient admitted due to a hemorrhagic episode of diverticulitis.
- S: Situation: the patient is experiencing a severe gastrointestinal hemorrhage, which is a common cause of lower gastrointestinal hemorrhage 2.
- B: Background: the patient's symptoms include massive and painless rectal hemorrhage, and initial resuscitative measures should include airway maintenance and oxygen supplementation, followed by measurement of hemoglobin and hematocrit levels, and blood typing and crossmatching 2.
- A: Assessment: the patient's condition is severe and requires immediate attention. Since CT angio is not available at this center, other diagnostic tests such as colonoscopy should be considered to identify the source of bleeding 2.
- R: Recommendation:
- Initial management should include intravenous fluid resuscitation and transfusion of packed red blood cells if necessary 2.
- Colonoscopy should be performed within 12 to 48 hours of presentation to identify the source of bleeding and potentially perform endoscopic therapeutic maneuvers 2.
- If the bleeding source is not identified, radionuclide imaging or arteriography should be considered 2.
- The patient should be closely monitored for signs of complications such as peritonitis or sepsis, which may require surgical intervention 3, 4.