What workup should be ordered for a 25-year-old male with right upper quadrant abdominal pain and bright red blood per rectum?

Diagnostic Workup for a 25-Year-Old Male with Right Upper Quadrant Pain and Rectal Bleeding

For a 25-year-old male with right upper quadrant pain and bright red blood per rectum with family history of colon cancer, a comprehensive workup should include immediate laboratory tests, abdominal imaging, and urgent colonoscopy within 24 hours to identify the source of bleeding and rule out malignancy. 1

Initial Assessment and Stabilization

• Hemodynamic assessment and stabilization

  • Monitor vital signs (already noted BP 176/92, pulse 107)
  • Establish IV access for fluid resuscitation if needed
  • Assess for signs of shock or ongoing significant bleeding

• Laboratory investigations

  • Complete blood count to assess hemoglobin and hematocrit
  • Coagulation profile (PT/INR, PTT)
  • Blood typing and cross-matching (given active bleeding)
  • Comprehensive metabolic panel including liver function tests (given RUQ pain)
  • Type and screen for potential blood transfusion 2, 1

Diagnostic Evaluation

Endoscopic Evaluation

• Urgent colonoscopy within 24 hours is strongly indicated due to:

  • Active rectal bleeding
  • Strong family history of colon cancer
  • Right upper quadrant pain that could indicate a proximal source 1

• Consider upper endoscopy if colonoscopy is negative, as up to 15% of patients with hematochezia may have an upper GI source 1

• Anoscopy or flexible sigmoidoscopy should be performed as first-line diagnostic tools to evaluate for anorectal causes of bleeding 2, 1

Imaging Studies

• Abdominal CT scan with contrast is indicated due to:

  • Right upper quadrant pain (to evaluate liver, gallbladder, biliary tract)
  • Need to assess for potential causes of bleeding not visible on endoscopy
  • Ability to detect active bleeding at rates as low as 0.3-1.0 mL/min 1

• Consider CT angiography if bleeding is active and severe, as it has high sensitivity (80-90%) for detecting active bleeding 1

Special Considerations

• Expedited workup is warranted given:

  • Young age (25) with family history of colon cancer
  • Combination of RUQ pain and rectal bleeding could indicate:
    • Inflammatory bowel disease
    • Ischemic colitis
    • Vascular malformation
    • Less commonly, metastatic disease

• Avoid common pitfalls:

  • Don't assume hemorrhoids are the cause without proper evaluation, especially with family history of colon cancer
  • Don't delay colonoscopy beyond 24 hours in this high-risk scenario
  • Don't overlook potential hepatobiliary causes of RUQ pain that could be related to bleeding (e.g., hemobilia) 3
  • Don't forget to perform digital rectal examination to characterize bleeding and rule out anorectal causes 2

Management Approach

1. Immediate stabilization with IV fluids if needed
2. Laboratory tests as outlined above
3. CT abdomen with contrast to evaluate RUQ pain and potential bleeding sources
4. Urgent colonoscopy within 24 hours after adequate bowel preparation
5. Consider upper endoscopy if colonoscopy is negative or if upper GI source is suspected
6. Endoscopic therapy if high-risk stigmata or active bleeding is identified 1, 4

This algorithmic approach prioritizes rapid diagnosis and intervention to minimize morbidity and mortality in this young patient with concerning symptoms and family history.