What is the most appropriate initial step in managing an elderly patient with hypertension (HTN) and a history of colorectal polyp, presenting with fresh blood per rectum, tachycardia, and pallor?

Initial Management: IV Fluid and Blood Product Resuscitation

The most appropriate initial step is B: IV fluid and blood product resuscitation. This elderly patient presents with clear signs of hemodynamic instability (tachycardia at 120 bpm, pallor) from active gastrointestinal bleeding, requiring immediate resuscitation before any diagnostic procedures 1, 2.

Immediate Resuscitation Protocol

Hemodynamic stabilization must occur before diagnostic evaluation. The patient's tachycardia (HR 120) and pallor indicate significant blood loss requiring urgent intervention 2.

First-Line Actions

• Establish two large-bore IV lines immediately for rapid fluid and blood product administration 1
• Begin crystalloid infusion targeting mean arterial pressure >65 mmHg while avoiding fluid overload 3, 1, 2
• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL during resuscitation (though hemoglobin level is not yet available, clinical signs of pallor and tachycardia warrant empiric transfusion) 3, 1, 2
• Correct any coagulopathy with appropriate blood products if present 3, 2

Why Not CT or Urgent Colonoscopy First?

CT Imaging (Option A)

• CT is not the priority in hemodynamically unstable patients - resuscitation takes precedence over diagnosis 1
• Delaying resuscitation to perform diagnostic procedures is a critical pitfall that increases mortality 1

Urgent Colonoscopy (Option C)

• Colonoscopy should only be performed after hemodynamic stabilization 3, 1
• The World Journal of Emergency Surgery explicitly states that "patients' conditions should be optimized before endoscopic intervention" 3
• While colonoscopy within 24 hours is appropriate for major bleeds, it follows—not precedes—resuscitation 1

Special Considerations in This Patient

Hypertension Management

• The elevated blood pressure (160/96) should not be aggressively treated during acute bleeding 3
• Avoid excessive blood pressure lowering that could precipitate cerebral, coronary, or renal ischemia 3
• The hypertension may be a compensatory response to maintain perfusion in the setting of blood loss

History of Colorectal Polyp

• This history increases suspicion for a lower GI source, but 10-15% of patients with severe hematochezia have an upper GI source 1
• The prior polyp history does not change the immediate management priority of resuscitation 1

Algorithmic Approach After Stabilization

Once hemodynamically stable (MAP >65 mmHg, HR normalizing):

1. Obtain hemoglobin level and continue transfusion to maintain >7 g/dL 3, 1, 2
2. Perform colonoscopy within 24 hours after adequate bowel preparation 1
3. Consider upper endoscopy if no clear lower GI source is identified, given the significant percentage of upper GI bleeding presenting as hematochezia 1

Critical Pitfalls to Avoid

• Never delay resuscitation for diagnostic procedures in hemodynamically unstable patients 1
• Avoid over-transfusion which may increase portal pressure and worsen bleeding if portal hypertension is present 1
• Do not assume lower GI source despite rectal bleeding presentation—always consider upper GI bleeding with hemodynamic instability 1