Should a patient with a history of hematochezia (passage of fresh blood per anus) 2 days ago, now presenting with stable vital signs and normal bowel movement, and a recent unremarkable colonoscopy, be admitted for further evaluation?

Disposition Decision for Resolved Hematochezia with Recent Normal Colonoscopy

This patient can be safely discharged home with urgent outpatient follow-up rather than admitted, provided they meet low-risk criteria on the Oakland score (≤8 points) and have stable vital signs with no active bleeding. 1

Risk Stratification Using the Oakland Score

Calculate the Oakland score immediately to determine disposition 1:

• Age: <40 (0 points), 40-69 (1 point), ≥70 (2 points)
• Gender: Female (0 points), Male (1 point)
• Previous LGIB admission: No (0 points), Yes (1 point)
• Digital rectal exam findings: No blood (0 points), Blood present (1 point)
• Heart rate: <70 (0 points), 70-89 (1 point), 90-109 (2 points), ≥110 (3 points)
• Systolic BP: <90 (5 points), 90-119 (4 points), 120-129 (3 points), 130-159 (2 points), ≥160 (0 points)
• Hemoglobin: <70 g/L (22 points), 70-89 (17 points), 90-109 (13 points), 110-129 (8 points), 130-159 (4 points), ≥160 (0 points)

Patients scoring ≤8 points with no other indications for hospital admission are suitable for immediate discharge with outpatient investigation. 1

Patients scoring >8 points should be admitted for inpatient colonoscopy on the next available list. 1

Critical Assessment Before Discharge

Verify Hemodynamic Stability

• Calculate shock index (heart rate ÷ systolic blood pressure) - a value >1 mandates admission regardless of Oakland score 2, 3
• Assess for orthostatic vital sign changes, which indicate significant blood loss requiring ICU-level care 4

Confirm No Active Bleeding

• Perform digital rectal examination to verify no fresh blood currently present 3
• Document that bowel movements have normalized without ongoing hematochezia 1

Consider Upper GI Source

Even with hematochezia, 10-15% of patients with severe bleeding and hemodynamic instability have an upper GI source. 1, 5, 6 However, in your stable patient with resolved bleeding 2 days ago, this is less concerning. If the patient had presented with hemodynamic instability, upper endoscopy would be mandatory first. 1, 5

Outpatient Management Plan

Timing of Outpatient Colonoscopy

Schedule colonoscopy within 2 weeks for patients over age 50 with unexplained rectal bleeding, as 6% have underlying colorectal cancer. 1 The recent unremarkable colonoscopy "a few months ago" provides some reassurance, but the exact timing matters:

• If colonoscopy was within 3-6 months and was high-quality with excellent preparation, the risk of missed pathology is lower
• If >6 months or preparation was suboptimal, repeat colonoscopy is warranted given the new bleeding episode 1

Anorectal Examination

Benign anorectal conditions account for 16.7% of lower GI bleeding diagnoses. 1 Before discharge, perform or arrange:

• Proctoscopy or anoscopy to evaluate for hemorrhoids, fissures, or other anorectal pathology 1
• This can be done in the emergency department or arranged as urgent outpatient follow-up 1

Common Pitfalls to Avoid

Do Not Discharge If:

• Oakland score >8 points 1
• Shock index >1 2, 3
• Ongoing active bleeding on rectal examination 1
• Hemoglobin <70 g/L or significant drop from baseline 1, 2
• Patient is on anticoagulation that cannot be safely managed outpatient 2, 3
• Significant comorbidities (cardiovascular disease, cirrhosis) that increase risk 2

Critical Safety Net Instructions

Provide explicit return precautions:

• Recurrent bleeding of any volume 1
• Lightheadedness, syncope, or orthostatic symptoms 2, 3
• Persistent tachycardia or hypotension 1
• New melena or hematemesis (suggesting upper GI source) 1, 5

Documentation Requirements

Document clearly:

• Oakland score calculation with individual components 1
• Shock index calculation 2, 3
• Digital rectal exam findings 1, 3
• Hemoglobin level and comparison to baseline 1, 2
• Details of prior colonoscopy (date, quality, findings) 1
• Explicit discharge instructions and follow-up plan 1

Special Considerations

Most lower GI bleeding (81%) stops spontaneously without intervention. 7 Your patient fits this pattern with resolved bleeding 2 days ago and current stability. However, the 5% mortality rate associated with severe hematochezia underscores the importance of proper risk stratification. 7

The recent unremarkable colonoscopy is reassuring but does not eliminate the need for repeat evaluation if the Oakland score or clinical judgment suggests higher risk, particularly given that diverticular disease (the most common cause of severe hematochezia at 30%) can bleed intermittently. 7, 8