What are the next steps for an 83-year-old woman presenting with hematochezia (blood in stool)?

Management of Hematochezia in an 83-Year-Old Woman

The next step for an 83-year-old woman with blood in stool should be an urgent colonoscopy within 24 hours, along with immediate assessment of hemodynamic status, complete blood count, and coagulation profile. 1, 2

Initial Assessment

Immediate Actions

• Check vital signs (heart rate, blood pressure) to assess hemodynamic stability 1
• Determine hemoglobin and hematocrit levels
• Assess coagulation parameters
• Perform blood typing and cross-matching if bleeding is severe 1
• Complete physical examination including digital rectal examination to characterize the bleeding and rule out anorectal causes 1

Risk Stratification

Elderly patients with hematochezia have higher mortality rates (20.24% vs. 7.2% in younger patients) and require careful assessment 3. Factors to consider:

• Hemodynamic instability (tachycardia, hypotension)
• Comorbidities (particularly cardiovascular disease)
• Medication use (anticoagulants, antiplatelets, NSAIDs)
• Volume of blood loss

Diagnostic Evaluation

Endoscopic Assessment

• Perform anoscopy or flexible sigmoidoscopy as first-line diagnostic tool 1
• Schedule urgent colonoscopy within 24 hours for patients with major bleeding 2
• Consider upper endoscopy if colonoscopy is negative, as up to 15% of patients with serious hematochezia have an upper GI source 1

Imaging Studies

• CT angiography if bleeding is active and severe (can detect bleeding rates as low as 0.3-1.0 mL/min) 2
• Consider imaging only if suspicion of concomitant anorectal diseases (abscess, inflammatory bowel disease, neoplasm) 1

Common Causes to Consider in Elderly Patients

1. Diverticular bleeding
2. Angiodysplasia
3. Hemorrhoids (though less common cause of significant bleeding)
4. Colorectal cancer (risk increases with age)
5. Ischemic colitis
6. Upper GI source with rapid transit (duodenal ulcer is most common cause of upper GI bleeding presenting as hematochezia) 4

Management Approach

Resuscitation (if needed)

• Intravenous fluid replacement
• Blood transfusion if hemoglobin drops below 7 g/dL (target 7-9 g/dL) 1
• Maintain mean arterial pressure >65 mmHg while avoiding fluid overload 1
• Correct coagulopathy if present

Therapeutic Interventions

• Endoscopic therapy (clips, thermal therapy, injection) once source is identified 2
• Angiographic embolization for persistent bleeding not controlled by endoscopy 2
• Surgical intervention if bleeding persists despite other interventions or requires >6 units of blood 2

Special Considerations for Elderly Patients

• Higher risk of mortality compared to younger patients 3
• More likely to be on medications affecting coagulation 3
• May have atypical presentations or difficulty communicating symptoms 5
• Higher prevalence of comorbidities that may complicate management 5

Pitfalls to Avoid

• Assuming hemorrhoids are the cause without proper evaluation (colorectal cancer risk increases with age)
• Delaying endoscopy in patients with significant bleeding
• Failing to consider upper GI sources (up to 15% of serious hematochezia cases) 1
• Overlooking medication-related causes, particularly anticoagulants and NSAIDs
• Excessive fluid resuscitation, which may exacerbate bleeding in certain conditions 1

Remember that elderly patients with GI bleeding have higher transfusion requirements, greater need for surgical intervention, and higher mortality rates than younger patients 3, 4. Prompt and thorough evaluation is essential to improve outcomes.