What is the most appropriate initial management for an elderly patient with a history of colonic polyps and hypertension, presenting with hematochezia, pallor, and tachycardia?

Initial Management: IV Fluid and Blood Products (Option C)

The most appropriate initial management is immediate resuscitation with IV fluids and blood products (Option C), as this patient presents with hemodynamic instability requiring stabilization before any diagnostic or therapeutic procedures. 1, 2

Rationale for Prioritizing Resuscitation

This elderly patient demonstrates clear signs of hypovolemic shock with:

• Tachycardia (HR 110) despite hypertension (BP 160/90, likely baseline given known hypertension) 1
• Pallor indicating significant blood loss 1
• Active bright red blood per rectum suggesting ongoing bleeding 2

Initial resuscitation and hemodynamic stabilization are critical and patients' conditions should be optimized before endoscopic intervention. 3 The guidelines explicitly state: "Do not delay resuscitation to perform diagnostic procedures; stabilization takes priority." 1, 2

Immediate Resuscitation Protocol

Vascular Access and Fluid Resuscitation

• Establish two large-bore venous cannulae in the antecubital fossae for rapid fluid and blood product administration 1, 2
• Begin aggressive crystalloid infusion immediately with target mean arterial pressure >65 mmHg 1, 2
• Insert urinary catheter to monitor hourly urine output with target >30 mL/hr 1, 2

Blood Transfusion Strategy

• Transfuse packed red blood cells with a hemoglobin threshold of 7 g/dL and target 7-9 g/dL 1, 2
• This restrictive transfusion strategy has been shown to improve outcomes in gastrointestinal bleeding 1
• However, avoid over-transfusion as it may increase portal pressure and potentially worsen bleeding 1, 2
• Maintain hemoglobin level >7 g/dL during the resuscitation phase 3

Coagulopathy Correction

• Monitor for coagulopathy and correct as necessary before any invasive procedures 3, 2
• Consider temporarily discontinuing any antiplatelet agents during the acute bleeding episode 1, 2

Why Not Urgent Colonoscopy or CT Angio First?

Colonoscopy Timing (Option A)

While urgent colonoscopy within 24 hours is recommended for patients with high-risk features or ongoing bleeding, it should only be performed after hemodynamic stabilization 3, 1, 2. Proceeding directly to colonoscopy in an unstable patient risks cardiovascular collapse during the procedure 1.

CT Angiography Timing (Option B)

CT angiography is valuable for localizing active bleeding sites, but should be performed only after initial stabilization 1, 2. In a hemodynamically unstable patient, the priority is resuscitation, not localization 1, 2.

Diagnostic Approach After Stabilization

Once hemodynamically stable, the diagnostic algorithm should proceed as follows:

Primary Diagnostic Modality

• Urgent colonoscopy within 24 hours is the first-line diagnostic approach after hemodynamic stabilization 3, 1, 2
• Ensure thorough bowel preparation to improve visualization 2
• Given the patient's known colonic polyps, these are a likely bleeding source, as polyps >1 cm with stalks have increased bleeding risk 4, 5

Alternative/Adjunctive Diagnostics

• Consider upper endoscopy to exclude an upper GI source, as up to 15% of patients with apparent lower GI bleeding have an upper GI source 3, 1, 2
• If CT angiography is needed for localization in cases of ongoing bleeding despite stabilization, it can be performed before colonoscopy 1, 2

Critical Pitfalls to Avoid

• Never delay resuscitation to perform diagnostic procedures - this is the most common and dangerous error 1, 2
• Avoid over-transfusion which may exacerbate bleeding by increasing portal pressure 3, 1, 2
• Do not proceed to emergency surgery without attempting to localize bleeding through radiological and/or endoscopic modalities first 1, 2
• Do not assume the known polyps are the bleeding source without excluding other causes, as patients with polyps may have other proximal sources of bleeding 3

Risk Stratification Context

This patient has multiple high-risk features for mortality:

• Age >65 years 3
• Tachycardia and signs of shock 3
• Active bright red blood indicating ongoing bleeding 3
• Known comorbidity (hypertension) 3

These factors mandate aggressive initial resuscitation before any diagnostic intervention 3, 1, 2.