What is the most appropriate initial management for a patient with colorectal polyps and hypertension presenting with bright red bloody stool, pallor, and tachycardia?

Initial Management: Fluid Resuscitation and Blood Transfusion First

The most appropriate initial management is B - fluid and blood transfusion, as this patient presents with hemodynamic instability (tachycardia at 110 bpm, pallor suggesting significant blood loss) requiring immediate resuscitation before any diagnostic procedures. 1

Immediate Resuscitation Protocol

Establish vascular access and begin aggressive fluid resuscitation immediately:

• Insert two large-bore peripheral intravenous cannulae in the antecubital fossae for rapid fluid and blood product administration 1
• Begin crystalloid infusion with a target mean arterial pressure >65 mmHg 1
• The patient's tachycardia (110 bpm) and pallor indicate significant volume depletion requiring urgent intervention 1, 2

Initiate blood transfusion strategy:

• Transfuse packed red blood cells with a hemoglobin threshold of 7 g/dL and maintain target hemoglobin of 7-9 g/dL 3, 1
• This restrictive transfusion strategy has been shown to improve outcomes in gastrointestinal bleeding and is associated with reduced mortality and decreased rebleeding rates 3, 1
• Avoid over-transfusion as it may increase portal pressure and potentially worsen bleeding 1

Monitoring During Resuscitation

Continuous hemodynamic monitoring is essential:

• Monitor vital signs continuously with automated monitors 1
• Insert urinary catheter to monitor hourly urine output with target >30 mL/hr 1
• Check hemoglobin, hematocrit, and coagulation parameters to evaluate bleeding severity 4
• Obtain blood typing and cross-matching given the severity of presentation 4

Timing of Colonoscopy

Urgent colonoscopy should be performed AFTER hemodynamic stabilization, not before:

• Once the patient is hemodynamically stable, proceed with urgent colonoscopy within 24 hours 3, 1, 2
• The patient's known colorectal polyps make colonoscopy the appropriate diagnostic modality, but only after resuscitation 3
• Performing colonoscopy before adequate resuscitation significantly increases procedural risk and mortality 1, 2

Additional Considerations for This Patient

The hypertension (BP 160/90) requires specific attention:

• Hypertension is a significant risk factor for delayed postpolypectomy hemorrhage, with an adjusted odds ratio of 5.6 5
• If this bleeding is related to recent polypectomy, the interval can be as long as 14 days in patients with hypertension 5
• Blood pressure should be controlled during resuscitation while maintaining adequate perfusion pressure 1

Consider upper GI source:

• Up to 15% of patients with apparent lower GI bleeding may have an upper GI source 1
• Consider upper endoscopy in addition to colonoscopy once stabilized 2

Critical Pitfall to Avoid

Never delay resuscitation to perform diagnostic procedures - stabilization always takes priority. 1, 2 Proceeding directly to colonoscopy (option A) in a hemodynamically unstable patient with tachycardia and pallor would be inappropriate and potentially dangerous. The patient requires volume replacement and blood products first to prevent cardiovascular collapse during the procedure.