What is the most appropriate management for an elderly woman with lower gastrointestinal (GI) bleeding, a diffusely tender abdomen, and fresh blood on perianal exam, who is stable after receiving a blood transfusion?

Management of Elderly Woman with Lower GI Bleeding and Diffuse Abdominal Tenderness

For this elderly woman who is hemodynamically stable after blood transfusion but has a diffusely tender abdomen with ongoing lower GI bleeding, urgent colonoscopy (Option C) is the most appropriate next step, as it allows both diagnosis and potential therapeutic intervention in stable patients, while the diffuse tenderness warrants investigation before proceeding to surgery.

Critical Clinical Context

The key distinguishing feature in this case is the diffusely tender abdomen, which raises concern for:

• Ischemic colitis
• Inflammatory bowel disease
• Infectious colitis
• Perforation risk

However, the patient's hemodynamic stability after transfusion is the decisive factor that determines the management pathway 1, 2.

Algorithmic Approach Based on Hemodynamic Status

Step 1: Confirm Hemodynamic Stability

• Calculate shock index (heart rate/systolic blood pressure) 1, 2
• Shock index >1 indicates instability requiring immediate CTA 1
• Since this patient is stable after transfusion, she does not meet criteria for immediate angiography 3

Step 2: Risk Stratification for Stable Patients

• The Oakland score should be calculated (includes age, gender, previous LGIB, digital rectal findings, heart rate, systolic BP, hemoglobin) 1, 4
• Oakland score >8 points requires hospital admission and colonoscopy 1
• Given diffuse abdominal tenderness and active bleeding, this patient clearly requires inpatient management

Step 3: Diagnostic and Therapeutic Intervention

Colonoscopy is the appropriate next step because:

• It provides both diagnosis and therapeutic capability in stable patients 4, 5
• The diffuse tenderness suggests a mucosal process (ischemia, colitis) that requires direct visualization 6
• Urgent colonoscopy identifies definite bleeding sources in 42-68% of cases and allows immediate endoscopic therapy 7, 8

Why Other Options Are Incorrect

Option A: Laparotomy - Premature and High Risk

No patient should proceed to emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities 3. The British Society of Gastroenterology explicitly states this as a strong recommendation 3. Emergency subtotal colectomy has significant morbidity and mortality and should be avoided without localization 3. Surgery is reserved only for patients who fail endoscopic or angiographic intervention, or those with exceptional circumstances like aortoenteric fistula 3.

Option B: Angiography - Reserved for Unstable Patients

Transcatheter arteriography is indicated for patients with massive bleeding causing hemodynamic instability or requiring >5 units of blood transfusion 3. The American College of Radiology guidelines clearly state that CTA followed by catheter angiography should be performed in hemodynamically unstable patients (shock index >1) 1. Since this patient is stable after transfusion, angiography is not the first-line approach 3.

Option D: Blood Transfusion - Already Completed

The patient has already received blood transfusion and is now stable 1, 2. Continuing transfusion alone without diagnostic investigation would be inappropriate management. Restrictive transfusion thresholds (Hb trigger 70 g/L for patients without cardiovascular disease, 80 g/L with cardiovascular disease) should guide further transfusion needs 3, 4.

Colonoscopy Preparation and Timing

• Rapid colon purge using 4-6 L of polyethylene glycol followed by colonoscopy within 24 hours optimizes detection and management 5, 6
• The PEG preparation improves cecal completion rates (74% vs 41% overall) and reduces poor preparation rates (5% vs 16%) 6
• For elderly patients with suspected sigmoid lesions, glycerin or water enemas may be considered as alternatives 6

Important Caveats

The diffuse abdominal tenderness is a critical warning sign that requires careful consideration:

• If the patient develops peritoneal signs or hemodynamic instability during preparation or procedure, immediate surgical consultation is warranted 3
• Ischemic colitis is the most common cause of acute lower GI bleeding in elderly patients and presents with abdominal tenderness 6
• Mortality in lower GI bleeding relates more to comorbidities than exsanguination (3.4% overall, but 18% for inpatient-onset bleeding and 20% for patients requiring ≥4 units) 1, 2

If the patient becomes unstable during workup:

• Immediately perform CTA to localize bleeding 1, 2
• Follow positive CTA with catheter angiography and embolization within 60 minutes 1
• Reserve surgery only after failure of angiographic intervention 3, 1