What is the appropriate diagnostic workup for a patient presenting with rectal bleeding, positive fecal occult blood test, elevated White Blood Cell count, and imaging suggestive of acute proximal duodenitis, possible duodenal ulcer, and/or acute pancreatitis?

From the Guidelines

For a patient presenting with rectal bleeding, positive fecal occult blood test, elevated White Blood Cell count, and imaging suggestive of acute proximal duodenitis, possible duodenal ulcer, and/or acute pancreatitis, I strongly recommend proceeding with an upper endoscopy as the first-line diagnostic and therapeutic investigation, as suggested by the American College of Gastroenterology practice guidelines and an American Gastroenterological Association expert statement 1.

Diagnostic Workup

The patient's presentation suggests an upper GI source of bleeding, which is supported by the CT findings of proximal duodenitis with possible duodenal ulcer. The elevated WBC count and positive fecal occult blood test further support this diagnosis.

• Additional labs to order include:
  • Complete blood count (CBC) with differential
  • Comprehensive metabolic panel (CMP)
  • Coagulation studies (PT/INR, PTT)
  • Type and screen for potential blood transfusion
• Imaging studies:
  • The patient has already undergone imaging suggestive of acute proximal duodenitis, possible duodenal ulcer, and/or acute pancreatitis
  • Consider contrast-enhanced computed tomography (CE-CT) or magnetic resonance imaging (MRI) to assess the severity of acute pancreatitis, if suspected 1

Management

While managing this patient, ensure:

• Adequate IV access
• Fluid resuscitation
• Monitor vital signs closely
• Consider proton pump inhibitor therapy (such as pantoprazole 40mg IV twice daily) prior to endoscopy 1
• The patient's elevated WBC count and imaging findings suggest possible dehydration and inflammation, which should be addressed promptly

Additional Considerations

• A colonoscopy should also be considered to evaluate the entire colon and rule out a concurrent lower GI source of bleeding
• The patient's presentation and imaging findings suggest a high risk of rebleeding, massive hemorrhage, and death, emphasizing the need for prompt and thorough diagnostic workup and management 1

From the Research

Diagnostic Workup for Rectal Bleeding and Suspected Upper Gastrointestinal Bleeding

• The patient's presentation of rectal bleeding, positive fecal occult blood test, elevated White Blood Cell count, and imaging suggestive of acute proximal duodenitis, possible duodenal ulcer, and/or acute pancreatitis suggests an upper gastrointestinal bleed 2, 3, 4.
• The first steps in managing a patient with suspected upper gastrointestinal bleeding include resuscitation with appropriate fluids and blood products as necessary 3, 4.
• Endoscopy is the diagnostic and therapeutic modality of choice for upper gastrointestinal bleeding and should be performed within 24 hours of presentation after initial stabilization 2, 3, 4, 5, 6.
• Intravenous proton pump inhibitors should be administered in the acute setting to decrease the probability of high-risk stigmata seen during endoscopy 3.
• The use of prokinetic agents, such as i.v. erythromycin, before endoscopy may improve endoscopic visualization, especially in patients with a suspected high probability of having blood or clots in the stomach 6.
• Risk stratification tools, such as the Glasgow Blatchford Score, can be used to assess the severity of bleeding and guide management 4.
• Transcatheter arterial embolization or surgical intervention may be necessary in some cases 4.
• Helicobacter pylori should be tested for in all patients with peptic ulcer bleeding and eradicated if positive 2.