Case Presentation: 56-Year-Old Female with Lower GI Bleeding and Multiple Comorbidities

Chief Complaint and Presentation

This patient presented with hematochezia in the setting of end-stage renal disease on hemodialysis, complicated by septic shock from fungemia and hospital-acquired pneumonia, ultimately leading to death from multiorgan failure. 1

Patient Demographics and Admission Details

Patient: Jacquelyn Quinto, 56-year-old female from Binmaley, Pangasinan 1
Admission Location: Female ward bed 3, Medicine service 1
Chief Complaint: Fresh blood in stools, 5 episodes per day following hemodialysis 1

History of Present Illness

Acute Presentation

Patient developed hematochezia immediately after hemodialysis on November 3,2025, with 5 episodes of fresh blood per day 1
Associated symptoms included poor appetite, nausea, and profound body weakness 1
No vomiting, orthopnea, dyspnea, syncope, or chest pain initially 1
Digital rectal examination confirmed blood on examining finger with full rectal vault 1

Progression During Hospitalization

Day 2-3: Continued hematochezia (2 episodes), developed substernal chest pain, increased sleepiness, and asterixis suggesting uremic encephalopathy 1
Day 4: New jaundice and bruising on abdomen and right arm, indicating worsening coagulopathy 1
Final Day: Patient expired 2 hours after hemodialysis with femoral catheter reinsertion 1

Past Medical History

Chronic Conditions

CKD Stage 5 since September-October 2024, requiring hemodialysis on Monday-Wednesday-Friday schedule 1
Acute MI (non-STEMI) diagnosed October 2024 1
Heart Failure with reduced ejection fraction (later corrected to HFpEF 52%) since October 2024 1
Non-compliant with maintenance medications 1

Recent Complications (2024-2025)

October 1-10,2024: Hypotensive episode 1
February 28,2025: Non-functioning internal jugular catheter due to catheter-related bloodstream infection, status post IJ catheter insertion 1
- Treated with Ceftriaxone and Piperacillin-Tazobactam 1
August 2025: Status post femoral catheter insertion 1
October 20,2025: Pneumonia treated with Cefixime and Levofloxacin 1

Negative History

No diabetes mellitus, no hypertension, no gout 1

Medications (Non-Compliant)

Sodium bicarbonate TID 1
Clopidogrel 75mg daily 1
Aspirin 80mg daily 1
Trimetazidine 35mg BID 1
Atorvastatin 40mg at bedtime 1
Ferrous sulfate + folic acid daily 1
Sevelamer carbonate 800mg TID 1
Erythropoietin 4000 IU subcutaneous 3x weekly post-hemodialysis 1

Social and Family History

Non-smoker, non-alcoholic beverage consumer 1
Unemployed 1
Family history: Paternal hypertension; negative for diabetes, tuberculosis, heart disease, or CKD 1
No known drug allergies 1
COVID-19 vaccination: Pfizer, 2 doses 1

Physical Examination Findings

Vital Signs on Admission

Blood pressure: 90/60 mmHg (hypotensive) 1
Heart rate: 108 bpm (tachycardic) 1
Respiratory rate: 20 breaths/minute 1
Temperature: 36.1°C 1
Oxygen saturation: 96% on room air 1
Shock index: 1.2 (HR 108 ÷ SBP 90 = >1, indicating hemodynamic instability) 1, 2

General Appearance

Awake, oriented, weak-appearing, not in cardiopulmonary distress 1
Marked pallor present 1
Glasgow Coma Scale: 15/15 1

Head, Eyes, Ears, Nose, Throat

Pale palpebral conjunctivae 1
Initially anicteric sclerae, later developed jaundice 1
No oral thrush or discharge 1

Cardiovascular

Adynamic precordium 1
Normal rate, regular rhythm 1
No murmurs 1

Respiratory

Initially: Rales in left mid-to-basal lung fields, clear breath sounds on right 1
Later: Coarse crackles bilateral mid-to-bibasal lung fields 1
No wheezes or retractions 1

Abdominal

Flat, non-distended 1
Tenderness in left lower quadrant and hypogastric area (pain score 5/10) 1
Hyperactive bowel sounds initially, later normoactive 1

Extremities

No edema 1
Later developed bruising on abdomen and right arm 1

Neurological

Asterixis developed during hospitalization (sign of uremic encephalopathy) 1

Laboratory Findings

Complete Blood Count

Initial (Day 1):

Hemoglobin: 96 g/L (severe anemia) 1
Hematocrit: 0.310 1
RBC: 3.64 × 10¹²/L 1
WBC: 28.13 × 10⁹/L (marked leukocytosis) 1
Neutrophils: 92% (left shift) 1
Lymphocytes: 4% (lymphopenia) 1
Platelets: 16 × 10⁹/L (severe thrombocytopenia) 1

Follow-up (Day 4):

Hemoglobin: 104 g/L (improved after transfusion) 1
WBC: 17.01 × 10⁹/L (improved but still elevated) 1
Platelets: 20 × 10⁹/L (minimal improvement despite 6 units platelet transfusion) 1

Chemistry Panel

BUN: 74.14 mmol/L (markedly elevated) 1
Creatinine: 1241.7 µmol/L initially, improved to 1080 µmol/L 1
SGOT/AST: 28 U/L 1
SGPT/ALT: <6 U/L 1
Sodium: 128.4 mmol/L, improved to 130 mmol/L (hyponatremia) 1
Potassium: 5.98 mmol/L, improved to 5.78 mmol/L (hyperkalemia) 1
Chloride: 93 mmol/L 1
Ionized calcium: 1.35 mmol/L 1
Magnesium: 0.95 mmol/L 1
Inorganic phosphorus: 4.49 mmol/L 1

Cardiac Markers

NT-proBNP: 11,217.4 pg/mL (markedly elevated, indicating severe heart failure) 1

Coagulation Studies

PT: 17.0 seconds (control 13.2) 1
INR: 1.33 1
aPTT: 85.1 seconds (control 33.0), ratio 2.58 (markedly prolonged) 1
D-dimer: 2250 ng/mL (elevated) 1

Infection Markers

Procalcitonin: 3.67 ng/mL initially, decreased to 2.38 ng/mL (indicating severe bacterial infection/sepsis) 1

Hemolysis Workup

Direct Coombs test: 3+ (positive, indicating autoimmune hemolytic anemia) 1
LDH: 183 U/L 1
Total bilirubin: 42.75 µmol/L (elevated) 1
Direct bilirubin: 3.42 µmol/L 1
Indirect bilirubin: 39.33 µmol/L (markedly elevated, consistent with hemolysis) 1

Blood Type

O positive 1

Imaging and Diagnostic Studies

Whole abdomen ultrasound: Ordered but results not documented 1
2D echocardiogram: Performed, showed ejection fraction 52% (HFpEF, not HFrEF as initially suspected) 1
Peripheral blood smear, fibrinogen, reticulocyte count: Sent but results not documented 1

Microbiological Studies

Blood cultures for Gram stain, culture, and sensitivity: Sent 1
Femoral catheter culture: Ordered 1
Final diagnosis: Fungemia (specific organism not documented) 1

Hospital Course and Management

Problem 1: Lower Gastrointestinal Bleeding (Probable Diverticulitis)

Initial management: Omeprazole 40mg IV every 12 hours 1
Racecadotril 100mg every 8 hours for symptomatic control 1
Tranexamic acid initially considered but later held due to coagulopathy concerns 1
Gastroenterology consultation requested 1
Critical issue: No colonoscopy was performed despite being the recommended first-line investigation for LGIB 3, 1

Problem 2: End-Stage Renal Disease

Hemodialysis attempted but complicated by poor vascular access 1
Last successful dialysis: November 3,2025 1
Hemodialysis deferred on one occasion due to poor access 1
Thoracic and cardiovascular surgery consultation for vascular access evaluation 1
Left femoral catheter reinserted on final day 1
Sevelamer 800mg TID for phosphate binding 1
Sodium chloride tablets TID 1
Sodium bicarbonate tablets for metabolic acidosis 1

Problem 3: Sepsis (Hospital-Acquired Pneumonia and Catheter-Related Bloodstream Infection)

Antibiotic regimen:
- Vancomycin every 48 hours (for MRSA coverage) 1
- Meropenem (broad-spectrum coverage) 1
Antifungal therapy:
- Fluconazole loading dose 400mg IV, then 400mg IV every 24 hours post-hemodialysis, 200mg IV on non-hemodialysis days 1
Infectious disease consultation obtained 1
Procalcitonin trended (3.67 → 2.38 ng/mL) 1

Problem 4: Heart Failure with Preserved Ejection Fraction (52%)

Empagliflozin 25mg daily 1
Trimetazidine 35mg BID 1
NT-proBNP: 11,217.4 pg/mL (markedly elevated) 1

Problem 5: Thrombocytopenia with Coagulopathy (Disseminated Intravascular Coagulation vs. Autoimmune Hemolytic Anemia)

Transfusion support:
- 6 units platelet concentrate transfused 1
- 1 unit packed red blood cells 1
Vitamin K 1 amp every 8 hours for 3 doses 1
Workup for DIC vs. AIHA with peripheral blood smear, fibrinogen, LDH, bilirubin, reticulocyte count 1
Positive direct Coombs test (3+) suggesting autoimmune component 1

Final Diagnosis and Cause of Death

Immediate Cause of Death

Septic shock secondary to hospital-acquired pneumonia 1

Antecedent Cause

Fungemia secondary to catheter-related bloodstream infection, complicated 1

Underlying Cause

Chronic kidney disease stage 5 secondary to chronic glomerulonephritis 1

Other Significant Conditions

Pancytopenia secondary to infection 1
Heart failure with preserved ejection fraction (52%) 1
Lower gastrointestinal bleeding (probable diverticulitis) 1

Time of Death

Patient expired 2 hours after hemodialysis with femoral catheter reinsertion 1

Critical Analysis and Additional Diagnostic Considerations

What Was Missing in This Case?

1. Urgent Colonoscopy Was Never Performed

The American Gastroenterological Association recommends colonoscopy as the first-line investigation for LGIB in hemodynamically stable patients after resuscitation 1, 2
This patient had a shock index >1 (1.2) on admission, indicating hemodynamic instability requiring urgent intervention 1, 2
For hemodynamically unstable patients with LGIB, CT angiography should be performed immediately to localize bleeding before any intervention 3, 1, 2
Neither colonoscopy nor CT angiography was documented in this case 1

2. Inadequate Management of Antiplatelet Therapy

Patient was on both clopidogrel and aspirin, which significantly increase bleeding risk 4
For patients with GI bleeding on antiplatelet therapy, clopidogrel should be temporarily discontinued if active bleeding is confirmed 4
No documentation of holding these medications initially 1
The American Gastroenterological Association recommends that aspirin for secondary prevention should not be routinely stopped; if stopped, restart as soon as hemostasis is achieved 1, 4

3. Suboptimal Transfusion Strategy

Initial hemoglobin was 96 g/L with ongoing bleeding and hemodynamic instability 1
For patients with cardiovascular disease (this patient had non-STEMI and HFpEF), the American Gastroenterological Association suggests using a higher transfusion threshold (Hb trigger 80 g/L, target 100 g/L) 1, 2
Only 1 unit PRBC was ordered, which was insufficient 1

4. Coagulopathy Not Adequately Corrected

Severe thrombocytopenia (16-20 × 10⁹/L) and prolonged aPTT (ratio 2.58) 1
The American Gastroenterological Association recommends correcting coagulopathy immediately by transfusing fresh frozen plasma for INR >1.5 and platelets for platelets <50,000/µL 1
While 6 units of platelets were given, no fresh frozen plasma was documented despite prolonged aPTT 1
Vitamin K was given, but this only addresses vitamin K-dependent factors, not the severe thrombocytopenia or prolonged aPTT 1

5. Delayed Recognition of Fungemia

Fluconazole was not started until November 8, several days after admission 1
Earlier empiric antifungal coverage should have been considered given the history of catheter-related bloodstream infection and persistent sepsis 1

6. Vascular Access Crisis

Patient had multiple failed vascular access attempts with history of IJ catheter infection and femoral catheter 1
Hemodialysis was deferred due to poor access, contributing to worsening uremia (asterixis, encephalopathy) 1
Earlier involvement of vascular surgery for permanent access (AV fistula or graft) should have been considered 1

7. No ICU Admission Despite Meeting Criteria

The American Gastroenterological Association suggests ICU admission if orthostatic hypotension is present, hematocrit decrease ≥6%, transfusion requirement >2 units, continuous active bleeding, or persistent hemodynamic instability 1
This patient met multiple criteria: shock index >1, hemoglobin 96 g/L, ongoing bleeding, sepsis with procalcitonin 3.67 ng/mL 1
Patient remained on general medical ward throughout hospitalization 1

Recommended Diagnostic Workup That Should Have Been Done

Immediate (Within 1 Hour of Admission)

CT angiography of abdomen and pelvis to localize bleeding source, given shock index >1 3, 1, 2
Type and cross-match for at least 4-6 units packed red blood cells given severity of bleeding and anemia 3, 1
Arterial blood gas to assess metabolic acidosis and lactate (marker of tissue hypoperfusion) 2

Within 24 Hours

Urgent colonoscopy after adequate resuscitation and bowel preparation if bleeding slows 3, 1, 5
Upper endoscopy to rule out upper GI source, as failure to consider this is a common pitfall in patients with hemodynamic instability 1, 2
Echocardiogram (was done, showed HFpEF 52%) 1

Additional Studies for Coagulopathy Workup

Fibrinogen level (was sent but result not documented) 1
Peripheral blood smear (was sent but result not documented) 1
Reticulocyte count (was sent but result not documented) 1
Haptoglobin to confirm hemolysis 1
Mixing study to differentiate factor deficiency from inhibitor given prolonged aPTT 1

Infection Workup

Blood cultures (were done) 1
Catheter tip culture after removal 1
Chest X-ray to evaluate pneumonia 1
Fungal blood cultures (1,3-beta-D-glucan, galactomannan) given high risk 1

What the Optimal Management Should Have Been

Immediate Resuscitation (First Hour)

Transfer to ICU immediately given shock index >1, severe anemia, thrombocytopenia, and sepsis 1
Two large-bore IV catheters for rapid volume expansion 2
Aggressive fluid resuscitation with crystalloids (normal saline or lactated Ringer's) to restore hemodynamic stability 2
Transfuse packed red blood cells to target hemoglobin >100 g/L given cardiovascular disease 1, 2
Transfuse platelets to target >50 × 10⁹/L given active bleeding 1
Transfuse fresh frozen plasma to correct prolonged aPTT 1
Hold clopidogrel and aspirin temporarily until bleeding controlled 4

Diagnostic Approach (First 24 Hours)

CT angiography immediately to localize bleeding source 3, 1, 2
If CTA shows active extravasation: Proceed to catheter angiography with embolization within 60 minutes 3, 1
If CTA negative but bleeding continues: Urgent colonoscopy after rapid bowel preparation 3, 1, 5
Upper endoscopy to rule out upper GI source 1, 2

Antibiotic/Antifungal Management

Continue broad-spectrum antibiotics (vancomycin + meropenem) for HAP and CRBSI 1
Start empiric antifungal therapy earlier (fluconazole or echinocandin) given history of CRBSI and persistent sepsis 1

Hemodialysis Management

Urgent vascular surgery consultation for permanent access (tunneled catheter, AV fistula, or graft) 1
Do not defer hemodialysis given severe uremia (BUN 74 mmol/L, creatinine 1241 µmol/L, asterixis, encephalopathy) 1
Consider continuous renal replacement therapy (CRRT) in ICU setting given hemodynamic instability 1

Heart Failure Management

Careful fluid balance given HFpEF and elevated NT-proBNP 1
Continue empagliflozin (appropriate for HFpEF) 1
Avoid excessive fluid resuscitation that could precipitate pulmonary edema 1

Coagulopathy Management

Aggressive platelet transfusion to maintain >50 × 10⁹/L during active bleeding 1
Fresh frozen plasma for prolonged aPTT 1
Consider prothrombin complex concentrate if INR significantly elevated 3, 1
Workup for DIC vs. AIHA (was initiated appropriately) 1
If AIHA confirmed: Consider corticosteroids or IVIG 1

Key Learning Points from This Case

Critical Errors That Contributed to Poor Outcome

No colonoscopy or CT angiography performed despite being the standard of care for LGIB 3, 1
Inadequate ICU-level care for a patient with shock index >1, severe sepsis, and multiorgan dysfunction 1
Suboptimal transfusion strategy for a patient with cardiovascular disease and active bleeding 1, 2
Delayed antifungal therapy despite high risk for fungemia from CRBSI 1
Inadequate correction of coagulopathy (no FFP given despite prolonged aPTT) 1
Deferred hemodialysis leading to worsening uremic encephalopathy 1

Prognostic Factors That Predicted Poor Outcome

Shock index >1 on admission (mortality increases to 40% with massive bleeding and hemodynamic instability) 3, 1
Procalcitonin >2 ng/mL indicating severe sepsis 1
Severe thrombocytopenia (<20 × 10⁹/L) with ongoing bleeding 1
Multiple comorbidities: ESRD, HFpEF, recent MI, HAP, fungemia 1
Inpatient-onset LGIB (mortality 18% vs. 3.4% for community-onset) 3, 1

Presentation Format for Rounds

Opening Statement: "This is a 56-year-old female with ESRD on hemodialysis who developed massive lower GI bleeding post-dialysis, complicated by septic shock from fungemia and HAP, who expired despite aggressive management."

One-Liner: "56F with ESRD on HD, recent MI, HFpEF, presenting with hematochezia, shock index 1.2, severe anemia (Hgb 96), thrombocytopenia (plt 16), and sepsis (procalcitonin 3.67), who developed fungemia and died from septic shock."

Assessment and Plan Format: Use the problem-based format as documented, but emphasize the critical missed opportunities for intervention (no CTA, no colonoscopy, no ICU admission, inadequate transfusion, delayed antifungals).

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