What is the most appropriate next step in management for an elderly woman with lower gastrointestinal (GI) bleeding, a diffusely tender abdomen, and ongoing instability despite receiving blood transfusions?

Emergency Laparotomy is Indicated

In an elderly woman with lower GI bleeding, diffuse abdominal tenderness, and persistent hemodynamic instability despite blood transfusion, emergency laparotomy (Option C) is the most appropriate next step. The combination of peritoneal signs (diffusely tender abdomen) and refractory shock suggests either bowel ischemia/infarction or perforation requiring immediate surgical intervention 1.

Critical Clinical Context

The diffusely tender abdomen fundamentally changes the management algorithm and represents a surgical emergency:

• Peritoneal signs with lower GI bleeding suggest bowel ischemia, infarction, or perforation - conditions that carry extremely high mortality without immediate surgical intervention 1
• Fulminant colonic ischemia, particularly in elderly patients, presents with colonic infarction and requires urgent surgery due to otherwise prohibitively high mortality rates 1
• The British Society of Gastroenterology acknowledges "exceptional circumstances" where proceeding directly to surgery is justified, specifically mentioning conditions like aortoenteric fistula 1

Why Not the Other Options

Angiography (Option B) - Wrong in This Context

While angiography is appropriate for hemodynamically unstable lower GI bleeding in general circumstances, it is contraindicated when peritoneal signs are present 2, 3:

• Angiography is recommended for unstable patients with isolated bleeding (shock index >1, requiring >5 units transfusion) without peritoneal signs 1
• The ACR guidelines state that "the choice between urgent colonoscopy, transcatheter arteriography, CTA, or surgery depends on the level of hemodynamic instability" - but this assumes no acute abdomen 1
• Delaying surgery to pursue angiography when peritoneal signs exist risks death from untreated bowel catastrophe 3

Emergency Colonoscopy (Option D) - Dangerous

Emergency colonoscopy is absolutely contraindicated in this patient 3:

• Colonoscopy requires hemodynamic stability and airway protection that unstable patients cannot safely tolerate 3
• The presence of diffuse abdominal tenderness raises concern for perforation or ischemia, making colonoscopy potentially catastrophic
• Guidelines uniformly recommend against colonoscopy in hemodynamically unstable patients 4, 3

FFP (Option A) - Insufficient Alone

While correcting coagulopathy (INR >1.5) with FFP is part of resuscitation 3, it is not the definitive next step when surgical pathology is present:

• FFP addresses coagulopathy but does nothing for the underlying surgical emergency
• The British Society of Gastroenterology recommends reversing anticoagulation with prothrombin complex concentrate and vitamin K in unstable GI hemorrhage 1
• Resuscitation must occur concurrently with definitive intervention, not as a substitute for it 3

The Surgical Imperative

The guidelines are clear about when to proceed directly to surgery 1:

• No patient should proceed to emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities, EXCEPT under exceptional circumstances 1
• Exceptional circumstances include aortoenteric fistula and, by extension, any condition suggesting bowel catastrophe 1
• Surgical intervention is required when hemodynamic instability persists despite aggressive resuscitation 1, 3
• Emergency surgery is indicated for hypotension and shock despite resuscitation 1

Critical Pitfall to Avoid

The most dangerous error is failing to recognize that diffuse abdominal tenderness with unstable lower GI bleeding represents a surgical abdomen, not simply a bleeding problem 1, 3:

• Proceeding to angiography or attempting colonoscopy delays life-saving surgery
• The mortality rate for emergency surgery in lower GI bleeding is 10% overall 1, but mortality approaches 100% for untreated bowel infarction
• While blind subtotal colectomy without localization carries 27-33% mortality 1, this is acceptable when the alternative is death from untreated ischemic bowel

Concurrent Management

While proceeding to the operating room 3:

• Continue aggressive volume resuscitation with crystalloid and packed red blood cells (target Hb >7 g/dL, consider >9 g/dL given cardiovascular stress) 3
• Correct coagulopathy with prothrombin complex concentrate and vitamin K if anticoagulated 1
• Maintain mean arterial pressure >65 mmHg 3
• On-table colonoscopy should be performed by colorectal surgeons if feasible to attempt localization and guide the extent of resection 1