What is the most appropriate next step in management for an unstable patient with lower GI bleeding and a diffusely tender abdomen?

Management of Unstable Lower GI Bleeding with Diffuse Abdominal Tenderness

In this unstable patient with lower GI bleeding and a diffusely tender abdomen despite blood transfusion, proceed immediately to laparotomy (Option C). The combination of hemodynamic instability refractory to resuscitation and diffuse abdominal tenderness suggests either bowel ischemia, perforation, or another surgical catastrophe requiring immediate operative intervention.

Critical Clinical Context

The diffuse abdominal tenderness fundamentally changes the management algorithm from standard lower GI bleeding protocols. This physical finding suggests:

• Bowel ischemia from mesenteric embolization (particularly if prior angiographic intervention was attempted) 1
• Perforation (which can occur with diverticular bleeding or other pathology)
• Intra-abdominal catastrophe requiring surgical exploration

The presence of peritoneal signs (diffuse tenderness) in an unstable bleeding patient mandates surgical exploration rather than further diagnostic studies. 1, 2

Why Not the Other Options?

Angiography (Option B) - Wrong in This Context

While the ACR Appropriateness Criteria recommend CTA or transcatheter arteriography/embolization as usually appropriate for hemodynamically unstable lower GI bleeding 1, these recommendations apply to patients without peritoneal signs.

• Angiography is appropriate for unstable bleeding when the patient has isolated hemorrhage without abdominal tenderness 1
• The 2021 ACR guidelines explicitly state that even in unstable patients, localization attempts should precede surgery when the patient can tolerate it 1
• A diffusely tender abdomen indicates the patient cannot safely undergo time-consuming diagnostic procedures 2

Emergency Colonoscopy (Option D) - Contraindicated

Emergency colonoscopy is explicitly contraindicated in this scenario:

• The American Gastroenterological Association and British Society of Gastroenterology recommend against colonoscopy when shock index >1 or patients remain unstable after resuscitation 2, 3
• Colonoscopy requires bowel preparation time that this patient cannot afford 1, 4
• Diffuse abdominal tenderness is a relative contraindication to colonoscopy due to perforation risk 3, 5

FFP (Option A) - Insufficient Alone

While correcting coagulopathy is important:

• FFP should be given for INR >1.5 as part of resuscitation 2, 3
• However, FFP alone does not address the underlying surgical emergency indicated by diffuse tenderness 2
• FFP can be administered simultaneously with preparation for surgery, but should not delay operative intervention 2, 6

Standard Algorithm for Unstable Lower GI Bleeding (Without Peritoneal Signs)

For context, the standard approach to unstable lower GI bleeding without diffuse tenderness would be:

1. Confirm instability: Shock index (HR/systolic BP) >1 2, 6
2. Aggressive resuscitation: Restrictive transfusion (Hb trigger 70 g/L without CVD, 80 g/L with CVD) 2, 6, 3
3. Immediate CTA: Fastest, least invasive localization method 1, 2
4. Catheter angiography with embolization: Within 60 minutes if CTA positive 1, 2
5. Surgery only if: Angiographic intervention fails or bleeding source cannot be localized 1

Why This Case Requires Immediate Surgery

The ACR guidelines state that "surgery without localization should only be reserved for uncontrollable GIB" 1, and the American Gastroenterological Association notes that "if patient remains unstable despite aggressive resuscitation, proceed directly to surgery" 2.

This patient meets both criteria:

• Unstable despite receiving blood (uncontrollable bleeding)
• Diffuse abdominal tenderness (surgical abdomen requiring exploration)

The guidelines acknowledge that while total colectomy has higher mortality, it remains necessary for nonlocalized bleeding when the patient is too unstable for localization attempts 1. The diffuse tenderness suggests a surgical emergency beyond simple hemorrhage.

Critical Pitfall to Avoid

Do not delay surgery to pursue imaging or endoscopy in an unstable patient with peritoneal signs. Mortality in lower GI bleeding relates more to comorbidities and delayed intervention than to the choice between limited versus total colectomy 2, 6. The 20% mortality rate in patients requiring ≥4 units of blood emphasizes the need for definitive intervention when resuscitation fails 2, 6.