What are the initial steps and further management for a patient presenting with bleeding in stool?

Australian Guidelines for Management of Bleeding in Stool

For patients presenting with bleeding in stool, immediate assessment of hemodynamic stability followed by a digital rectal examination is mandatory, with subsequent diagnostic evaluation via ano-proctoscopy or flexible sigmoidoscopy as first-line investigation. 1

Initial Assessment and Resuscitation

Immediate Steps to Document:

1. Assess hemodynamic stability:

   • Calculate shock index (heart rate divided by systolic blood pressure)
   • Document vital signs (shock index >1 indicates hemodynamic instability)
   • Assess for signs of hypovolemia (tachycardia, hypotension)

2. Perform digital rectal examination:

   • Document color, volume, and characteristics of blood
   • Note presence of masses or hemorrhoids

3. Order initial laboratory tests:

   • Complete blood count
   • Coagulation profile
   • Blood typing and cross-matching (if severe bleeding)
   • Document baseline hemoglobin and hematocrit

4. Begin resuscitation if unstable:

   • Establish two large-bore IV access
   • Initiate fluid resuscitation with crystalloids
   • Transfuse packed red blood cells to maintain hemoglobin >7 g/dL (>9 g/dL for patients with cardiovascular disease or massive bleeding) 2, 1
   • Correct coagulopathy if present

Risk Stratification

Document risk assessment using validated tools:

• For lower GI bleeding: Use the Oakland score
  • Score ≤8 indicates minor bleed
  • Score >8 indicates major bleed 1

Diagnostic Evaluation

Immediate Diagnostic Steps:

1. Ano-proctoscopy or flexible sigmoidoscopy as first-line diagnostic tool 2, 1

   • Document findings (hemorrhoids, fissures, inflammatory changes)

2. Upper and lower GI endoscopy for stable patients

   • Upper endoscopy to exclude upper GI source
   • Colonoscopy within 24 hours after adequate bowel preparation 2, 3

3. CT angiography for patients with ongoing bleeding who are hemodynamically stable after resuscitation 2, 1

   • Can detect bleeding at rates of 0.3-1.0 mL/min

Documentation of Findings:

• Source of bleeding (if identified)
• Presence of high-risk stigmata (active bleeding, visible vessel, adherent clot)
• Extent and severity of bleeding

Management Plan

For Hemodynamically Stable Patients:

1. Endoscopic evaluation:

   • Upper endoscopy and colonoscopy to localize bleeding source 2, 1
   • Document endoscopic findings and interventions

2. Endoscopic hemostasis for high-risk stigmata:

   • Document technique used (mechanical, thermal, injection, or combination)
   • Document achievement of hemostasis

3. Medical management:

   • Proton pump inhibitors for upper GI sources
   • Correction of coagulopathy
   • Discontinuation of NSAIDs and assessment of anticoagulant/antiplatelet therapy 1

For Hemodynamically Unstable Patients:

1. Aggressive resuscitation:

   • Document fluid and blood product administration
   • Target hemoglobin >7-9 g/dL 2, 1

2. Urgent endoscopy after initial resuscitation 2

3. Consider radiological intervention if endoscopy unsuccessful:

   • CT angiography
   • Angiography with embolization 2, 1, 3

4. Surgical intervention for:

   • Persistent hemodynamic instability despite aggressive resuscitation
   • Requirement of more than 6 units of blood transfusion
   • Recurrence of severe bleeding 1
   • Document surgical approach and findings

Follow-up Plan

1. Iron supplementation for patients with anemia

   • IV iron for hemoglobin below 10 g/dL 1

2. Age-appropriate cancer screening

   • Colorectal cancer is found in 6% of patients with rectal bleeding 1

3. Medication review:

   • Avoid NSAIDs in patients with history of GI bleeding
   • Plan for reintroduction of antithrombotic therapy based on bleeding risk vs. thrombotic risk 1

Important Caveats

• Hospital mortality for lower GI bleeding is 3.4%, increasing to 18% for in-hospital bleeding 1
• Mortality is generally related to comorbidities rather than exsanguination
• Common causes of rectal bleeding include hemorrhoids, diverticular disease, angiodysplasia, and colorectal cancer 1
• Patients with inflammatory bowel disease and refractory hemorrhage may require subtotal colectomy with ileostomy 2
• Recurrent significant GI bleeding is an indication for urgent surgery 2