What is the next best step in managing hematochezia after blood transfusion?

Management of Hematochezia After Blood Transfusion

For patients with hematochezia after blood transfusion, CT angiography should be performed immediately if the patient is hemodynamically unstable or has a shock index >1, followed by urgent colonoscopy within 24 hours once the patient is stabilized. 1

Initial Assessment and Stabilization

• Ensure hemodynamic stability:

  • Maintain mean arterial pressure >65 mmHg
  • Use restrictive transfusion strategy (Hb trigger 70 g/L, target 70-90 g/L) unless patient has cardiovascular disease (trigger 80 g/L, target 100 g/L) 1
  • Actively warm the patient and all transfused fluids 1

• Laboratory evaluation:

  • Complete blood count
  • Coagulation profile (PT, aPTT, fibrinogen)
  • Type and cross-match 1
  • Target fibrinogen levels >1.5 g/L and platelet count >75 × 10⁹/L 2

Diagnostic Algorithm

1. For hemodynamically unstable patients or those with ongoing active bleeding:

   • CT angiography should be performed immediately 1
   • If no source identified on CTA, immediate upper endoscopy should follow 1
   • Up to 15% of patients presenting with serious hematochezia have an upper GI source 3

2. For hemodynamically stable patients:

   • Urgent colonoscopy within 24 hours 1
   • Consider bowel preparation to clear the colon of blood, clots, and stool for better visualization 4
   • Upper endoscopy should be performed before colonoscopy if upper GI source is suspected 1

Therapeutic Interventions

Based on diagnostic findings:

1. If bleeding source identified on CT angiography:

   • Proceed to catheter angiography with embolization within 60 minutes for unstable patients 1

2. If bleeding source identified on colonoscopy:

   • Endoscopic therapy with epinephrine injections, bipolar coagulation, or both 5
   • These interventions can prevent recurrent bleeding and decrease the need for surgery 5

3. If bleeding source identified as anorectal varices:

   • Use local procedures such as endoscopic variceal ligation, band ligation, or sclerotherapy 1

4. For coagulopathy management:

   • Correct coagulopathy aggressively 1
   • Consider tranexamic acid for patients with ongoing bleeding 6
   • For patients on warfarin, reverse anticoagulation with prothrombin complex concentrate and vitamin K 1

Post-Management Care

• Admit to critical care area for monitoring and observation 1
• Continue monitoring coagulation parameters, hemoglobin, and blood gases 1
• Initiate standard venous thromboprophylaxis once bleeding is controlled 1
• For patients on anticoagulants:
  • Restart aspirin for secondary prevention as soon as hemostasis is achieved 1
  • Consider restarting warfarin at 7 days after hemorrhage in patients with low thrombotic risk 1
  • For patients with high thrombotic risk, consider low molecular weight heparin at 48 hours after hemorrhage 1

Common Pitfalls to Avoid

1. Delayed intervention: Catheter angiography should be performed as soon as possible after positive CTA to maximize success 1

2. Premature surgery: No patient should proceed to emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities 1

3. Overlooking upper GI sources: Up to 15% of patients with severe hematochezia have an upper GI source 3

4. Inadequate bowel preparation: Poor visualization during colonoscopy due to inadequate bowel preparation can miss bleeding sources 4

5. Overaggressive fluid resuscitation: While maintaining adequate organ perfusion is important, fluid overload should be avoided 1