Can a patient with a history of lower gastrointestinal bleeding (LGIB) requiring transfusion, presenting with stable hemoglobin (Hgb) levels, be discharged or does she require immediate surgery 20 days prior to a scheduled outpatient hemorrhoidectomy?

Management of Patient with Lower Gastrointestinal Bleeding and Scheduled Hemorrhoidectomy

The patient with stable hemoglobin of 10.4 g/dL and a history of LGIB can be safely discharged with close follow-up, as they do not require immediate surgery based on their Oakland score and stable condition. 1

Risk Assessment Using Oakland Score

For this patient, we should calculate the Oakland score to determine the appropriate management:

• Age (not provided, but assuming 40-69): 1 point
• Gender (female): 0 points
• Previous LGIB admission (yes): 1 point
• DRE findings (not provided, assuming no blood): 0 points
• Heart rate (not provided, assuming normal 70-89): 1 point
• Systolic blood pressure (not provided, assuming normal 130-159): 2 points
• Hemoglobin 10.4 g/dL (104 g/L): 13 points

Total estimated Oakland score: 18 points

Management Decision Algorithm

1. Assess stability and severity:

   • The patient has a stable hemoglobin of 10.4 g/dL
   • Estimated Oakland score >8 points (approximately 18)
   • History of LGIB requiring transfusion

2. Discharge vs. Admission decision:

   • Oakland score >8 indicates this is a major bleed 1
   • Patient likely requires hospital admission for monitoring
   • If admitted, no immediate surgery is needed as the patient is hemodynamically stable

3. Timing of hemorrhoidectomy:

   • Maintain the scheduled outpatient hemorrhoidectomy in 20 days
   • No evidence supports immediate surgery over the planned procedure 1, 2
   • Hemorrhoids can be a source of transfusion-dependent bleeding 3, making the scheduled procedure appropriate

Important Considerations

• Monitoring during admission: If admitted, monitor vital signs, hemoglobin levels, and watch for signs of active bleeding
• Transfusion threshold: Consider transfusion only if hemoglobin drops below 7 g/dL or if the patient becomes symptomatic 4
• Diagnostic workup: While admitted, consider colonoscopy to confirm hemorrhoids as the bleeding source and rule out other causes 2

Potential Pitfalls

• Missing alternative diagnoses: Although hemorrhoids are the presumed cause given the scheduled hemorrhoidectomy, other sources of LGIB should be considered if bleeding persists
• Premature discharge: If the Oakland score is miscalculated due to missing information or the patient has other risk factors, premature discharge could lead to complications
• Delayed intervention: If bleeding worsens significantly during admission, the surgical plan may need to be reconsidered

The British Society of Gastroenterology guidelines recommend that patients with major bleeding (Oakland score >8) benefit from hospital admission 1. However, immediate surgery is not indicated for this hemodynamically stable patient with adequate hemoglobin levels. The scheduled hemorrhoidectomy in 20 days remains appropriate unless clinical deterioration occurs.