What is the initial approach for a 70-year-old patient presenting with sudden abdominal tenderness, normal abdominal ultrasound (U/S) and examination, but low hemoglobin (HB) percentage?

From the Guidelines

For a 70-year-old patient with sudden abdominal tenderness, normal abdominal ultrasound and examination, but low hemoglobin, the initial approach should focus on identifying and addressing the potential gastrointestinal bleeding, and I recommend starting with an urgent CT scan of the abdomen with IV contrast, as suggested by the most recent guidelines 1. The patient's presentation with sudden abdominal tenderness and low hemoglobin percentage raises concern for a gastrointestinal bleed, which can be life-threatening if not promptly addressed.

• The first step should be to assess the patient's hemodynamic stability, with vital signs monitoring and establishment of intravenous access for potential fluid resuscitation with isotonic crystalloids if necessary.
• Blood typing and cross-matching should be ordered for possible transfusion if hemoglobin is below 7-8 g/dL or if the patient is symptomatic, as recommended by guidelines 1.
• The next diagnostic step should be an urgent CT scan of the abdomen with IV contrast to evaluate for conditions that ultrasound might miss, such as mesenteric ischemia, small bowel pathology, or retroperitoneal bleeding, as suggested by recent radiologic management guidelines 1.
• Concurrently, an upper endoscopy and/or colonoscopy should be arranged within 24 hours to directly visualize potential bleeding sources, as recommended by guidelines for the management of lower gastrointestinal bleeding 1.
• While awaiting these procedures, the patient should remain NPO (nothing by mouth), receive appropriate pain management with medications like morphine 2-4 mg IV every 4 hours as needed, and undergo serial hemoglobin measurements every 6-8 hours to monitor for ongoing blood loss. This comprehensive approach is necessary because the combination of abdominal tenderness and unexplained anemia in an elderly patient raises concern for serious conditions that require prompt diagnosis and intervention, even when initial imaging appears normal.

From the Research

Initial Approach for a 70-year-old Patient with Sudden Abdominal Tenderness and Low Hemoglobin

• The patient's presentation of sudden abdominal tenderness, normal abdominal ultrasound and examination, but low hemoglobin percentage, suggests a possible gastrointestinal bleed 2, 3.
• Given the patient's age and low hemoglobin, it is essential to investigate the cause of the anemia, which may be related to a gastrointestinal malignancy or other benign causes 2.
• The initial approach should include a diagnostic work-up to identify the source of the bleeding, which may involve:
  • Occult stool testing by FIT (Fecal Immunochemical Test) to detect hidden blood in the stool 2.
  • Endoscopy and colonoscopy to visualize the upper and lower gastrointestinal tract 2, 4.
  • Abdominal CT (Computed Tomography) scan to evaluate the abdominal cavity and detect any potential sources of bleeding 3.

Diagnostic Considerations

• The patient's low hemoglobin percentage and normal abdominal examination suggest a possible occult gastrointestinal bleed 2, 3.
• The use of capsule endoscopy may be considered if the initial diagnostic work-up is negative, especially in elderly patients with obscure gastrointestinal bleeding 5.
• Push enteroscopy and intraoperative enteroscopy may also be useful in detecting the source of bleeding in the small intestine 4, 6.

Next Steps

• Based on the patient's presentation and diagnostic results, the next steps may involve:
  • Targeted treatment of any identified cause of anemia or bleeding 2.
  • Iron supplementation to normalize hemoglobin levels and replenish iron stores 2.
  • Further diagnostic testing, such as capsule endoscopy or push enteroscopy, if the initial work-up is negative 3, 4, 5, 6.