What is the appropriate management for a 72-year-old female presenting with hematochezia (passage of bloody stools) first thing in the morning?

Management of Morning-Only Hematochezia in a 72-Year-Old Female

This patient requires urgent colonoscopy within 24 hours after adequate bowel preparation, as she meets criteria for major lower GI bleeding based on age >70 years, and colonoscopy is the preferred initial diagnostic and therapeutic modality for acute lower GI bleeding. 1, 2

Initial Assessment and Risk Stratification

Immediate hemodynamic evaluation is essential:

• Check vital signs including heart rate and blood pressure to calculate shock index (heart rate/systolic BP) 3, 2
• A shock index <1 defines hemodynamic stability 3
• Obtain complete blood count with hemoglobin/hematocrit, coagulation parameters, serum electrolytes, BUN, and creatinine 1, 2
• Perform blood typing and cross-matching if signs of severe bleeding are present 1, 2

Apply the Oakland score for risk stratification:

• This 72-year-old female scores at minimum 2 points for age ≥70 years 1
• Additional points accrue based on: previous LGIB admission (+1), blood on digital rectal exam (+1), heart rate (0-3 points), systolic BP (0-5 points), and hemoglobin level (0-22 points) 1
• A score >8 classifies this as a major bleed requiring hospital admission 1
• Patients scoring ≤8 with no other indications can be discharged for urgent outpatient investigation 1

Diagnostic Algorithm

For hemodynamically stable patients (most likely scenario given morning-only bleeding):

• Perform digital rectal examination and anoscopy/proctoscopy first to identify common anorectal causes such as hemorrhoids, fissures, or rectal pathology 1, 2
• Assessment of the anal canal and rectum is mandatory in all patients with LGIB, as benign anorectal conditions account for 16.7% of diagnoses 1
• Proceed to colonoscopy within 24 hours after adequate bowel preparation as the initial diagnostic procedure 1, 2, 4
• Colonoscopy has diagnostic yields of 42-90% and allows for both diagnosis and therapeutic intervention 1

For hemodynamically unstable patients:

• Initiate immediate IV fluid resuscitation to normalize blood pressure and heart rate 1, 2
• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL (use >9 g/dL threshold if massive bleeding or cardiovascular comorbidities present) 1, 3, 2
• Perform CT angiography as first-line investigation before endoscopy 3, 2
• CTA detects bleeding at rates as low as 0.3 mL/min and helps localize the source 3, 2
• Consider emergency panendoscopy before purge to exclude upper GI bleeding, as rapid upper GI bleeding can present with hematochezia 2

Colonoscopy Preparation and Timing

Key considerations for optimal colonoscopy:

• Thorough bowel preparation is essential to improve visualization, as poor preparation leads to incomplete mucosal evaluation 5
• The diagnostic accuracy of colonoscopy ranges from 72-86% in patients with lower GI bleeding 5
• Complete colonoscopy with terminal ileum intubation is recommended 6
• Examination of the rectum with retroflexion (J-maneuver) provides useful information about hemorrhoidal disease and low rectal pathology 1

Therapeutic Interventions During Colonoscopy

If bleeding source is identified:

• Provide endoscopic hemostasis therapy for high-risk stigmata including active bleeding, non-bleeding visible vessel, or adherent clot 4
• Hemostasis modalities include mechanical therapy, thermal therapy, injection therapy, or combination approaches 4
• The specific modality is guided by bleeding etiology, access to the bleeding site, and endoscopist experience 4

Special Considerations for This Age Group

Common causes in elderly patients:

• Diverticulosis and angiodysplasia are leading causes in patients >70 years 7
• Angiodysplasia most commonly occurs in the cecum and proximal ascending colon (54%), followed by sigmoid colon (18%) and rectum (14%) 5
• Approximately 6% of patients presenting with LGIB have underlying bowel cancer, making timely investigation critical 1

If Initial Colonoscopy is Inconclusive

Repeat colonoscopy should be the first step:

• Ensure thorough bowel preparation to improve visualization 5
• Consider repeat colonoscopy with endoscopic hemostasis for evidence of recurrent bleeding 4

If repeat colonoscopy fails to identify the source:

• Perform radionuclide imaging with [99Tcm] pertechnetate-labeled red blood cells 5
• Scintigraphy detects active bleeding at rates of 0.1-0.5 mL/min and is more sensitive than angiography 5
• Early scans (<4 hours after baseline) are more helpful in localizing the bleeding site 5
• Angiography should be performed only after positive scintigraphy or in patients with hemodynamic instability 5

Critical Pitfalls to Avoid

• Do not delay CT angiography in unstable patients—it should be performed before endoscopy 3, 2
• Do not assume lower GI source without excluding upper GI bleeding, especially if hemodynamically unstable 2
• Avoid narcotic medication for sedation during colonoscopy, as it may decrease sensitivity for detecting angiodysplasia by transiently decreasing mucosal blood flow 5
• Recognize that approximately 20% of patients requiring ≥4 units transfusion have significant mortality risk 3
• Do not discharge patients with Oakland score >8 without hospital admission and investigation 1