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

Management of Stable Lower GI Bleeding with Diffuse Abdominal Tenderness

This patient requires emergency laparotomy (Option A) despite being hemodynamically stable after transfusion, because diffuse abdominal tenderness in the setting of lower GI bleeding represents a surgical abdomen indicating bowel catastrophe (ischemia, infarction, or perforation) rather than simple hemorrhage. 1

Critical Clinical Recognition

The key distinguishing feature in this case is diffuse abdominal tenderness, which fundamentally changes the management algorithm:

• 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 and, by extension, any condition suggesting bowel catastrophe 2, 1

Why Not the Other Options?

Why Not Angiography (Option B)?

• CT angiography is indicated for hemodynamically unstable patients (shock index >1) or those with active bleeding without peritoneal signs 2, 3
• This patient's diffuse abdominal tenderness indicates a surgical problem, not simply a localization problem 1
• Angiography would only delay necessary surgery and worsen outcomes 1

Why Not Urgent Colonoscopy (Option C)?

• Colonoscopy is the appropriate choice for stable patients WITHOUT peritoneal signs 2, 3, 4
• The British Society of Gastroenterology recommends colonoscopy for major bleeds in stable patients, but this assumes no surgical abdomen 2
• Colonoscopy has no role when diffuse tenderness suggests transmural bowel pathology 1

Why Not Blood Transfusion Alone (Option D)?

• Blood transfusion is supportive care, not definitive management 2
• The patient has already received transfusion and is now stable, but the underlying surgical pathology remains unaddressed 1
• Restrictive transfusion thresholds (Hb trigger 70 g/L, or 80 g/L with cardiovascular disease) should guide further transfusion needs, but surgery is the priority 2

The Surgical Imperative

The most dangerous error is failing to recognize that diffuse abdominal tenderness with lower GI bleeding represents a surgical abdomen, not simply a bleeding problem 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 2, 3
• Exceptional circumstances include aortoenteric fistula and any condition suggesting bowel catastrophe 2, 1
• Emergency surgery is indicated for hypotension and shock despite resuscitation, but also for peritoneal signs indicating transmural pathology 1

Concurrent Surgical Management

While preparing for laparotomy:

• Continue aggressive volume resuscitation with crystalloid and packed red blood cells (target Hb >7 g/dL, consider >9 g/dL given cardiovascular stress from potential sepsis/ischemia) 1
• Correct coagulopathy with prothrombin complex concentrate and vitamin K if anticoagulated 2, 1
• On-table colonoscopy should be performed by colorectal surgeons if feasible to attempt localization and guide the extent of resection 2, 1
• Surgery should ideally be performed by colorectal surgeons who can perform on-table colonoscopy or in collaboration with medical endoscopists 2

Mortality Context

• The mortality rate for emergency surgery in lower GI bleeding is 10% overall, but this must be weighed against near-certain mortality from untreated bowel infarction or perforation 1
• Emergency subtotal colectomy has significant morbidity and mortality, but is life-saving when indicated 2, 3