What is the appropriate management for a patient with sudden onset of rectal bleeding?

Management of Sudden Rectal Bleeding

Immediate hemodynamic assessment and stabilization take priority, followed by urgent diagnostic evaluation to identify the bleeding source—with the specific approach determined by hemodynamic stability, bleeding severity, and patient risk factors.

Initial Assessment and Resuscitation

Hemodynamic Stabilization

• Check vital signs immediately to assess for signs of hypovolemic shock (tachycardia, hypotension) and determine bleeding severity 1
• Obtain urgent laboratory studies including complete blood count, coagulation parameters, blood type and cross-match 1
• Initiate intravenous fluid resuscitation with crystalloids, avoiding fluid overload which can exacerbate bleeding 2, 1
• Maintain hemoglobin >7 g/dL during resuscitation and mean arterial pressure >65 mmHg 2, 3, 1
• Transfuse packed red blood cells if hemoglobin drops below 7 g/dL or ongoing hemorrhage is evident 1
• Correct coagulopathy and optimize management of anticoagulant/antiplatelet agents through multidisciplinary consultation 2, 3

Critical Risk Stratification

• High-risk features requiring urgent intervention (within 24 hours): hemodynamic instability, ongoing bleeding, hemoglobin drop ≥1.5 g/dL, or need for blood transfusion 2
• Patients on anticoagulation therapy require special attention due to increased risk of complications including intramural hematoma and perforation 4

Diagnostic Approach Based on Clinical Stability

For Hemodynamically Unstable Patients

• CT angiography (CTA) should be the initial diagnostic test with sensitivity of 79-95% and specificity of 95-100% for detecting active bleeding, without requiring bowel preparation 1
• Avoid delaying CTA by attempting colonoscopy first in unstable patients 1
• If CTA fails to identify the source, proceed immediately with upper endoscopy to rule out upper GI bleeding, as up to 15% of patients with apparent lower GI bleeding have an upper GI source 2, 1

For Hemodynamically Stable Patients

• Perform digital rectal examination or flexible sigmoidoscopy to identify common anorectal causes (hemorrhoids, anal fissures, rectal varices) 1, 5
• Full colonoscopy is necessary if: patient has risk factors for colorectal cancer (risk ranges 2.4-11% in patients with rectal bleeding), suspicion of proximal bleeding source, or initial examination is non-diagnostic 2, 1, 6
• Consider upper endoscopy if colonoscopy is negative, as 8-15% may have upper GI sources 1

Management of Specific Bleeding Sources

Anorectal Varices (Portal Hypertension-Related)

Non-Operative Management:

• Multidisciplinary approach with hepatology involvement is essential 2, 3, 1
• For mild bleeding: IV fluid replacement, blood transfusion if needed, correction of coagulopathy, and optimization of portal hypertension medications 2, 3
• For severe bleeding: maintain Hb >7 g/dL and MAP >65 mmHg while avoiding fluid overload (which increases portal pressure) 2, 3
• Administer prophylactic antibiotics (short course strongly recommended) 3
• Consider vasoactive drugs (terlipressin or octreotide) to reduce splanchnic blood flow and portal pressure 3, 1

Endoscopic Interventions:

• Local endoscopic procedures are first-line treatment where feasible 3
• Options include endoscopic variceal ligation (EVL) or EUS-guided glue injection 3
• Urgent colonoscopy within 24 hours for high-risk features or ongoing bleeding 2, 3

Advanced Management for Refractory Bleeding:

• Step-up approach with radiological interventions when medical and endoscopic treatments fail 3, 1
• Embolization via interventional radiology for short-term bleeding control 3, 7
• Transjugular intrahepatic portosystemic shunt (TIPS) for severe portal hypertension if not contraindicated 3, 1
• Surgical procedures as last resort when all other modalities fail 3, 1

Other Bleeding Sources

• Dieulafoy's lesions: Endoscopic management with thermal, mechanical (hemoclips/band ligation), or combination therapy (adrenaline injection plus thermal/mechanical) as first-choice treatment 8
• Traumatic or iatrogenic rectal bleeding: Consider arterial embolization if endoscopy fails to control hemorrhage 7
• Proctitis (inflammatory, infectious, radiation-induced): Requires interdisciplinary diagnostics and treatment including conservative, topical, interventional, and surgical options 5

Common Pitfalls to Avoid

• Do not delay CTA in unstable patients by attempting colonoscopy first 1
• Do not rely on gastric lavage for suspected upper GI bleeding—it provides no reliable diagnosis and may cause complications 1
• Do not wait for fever to diagnose infection in patients with retained tissue or suspected sepsis; look for tachycardia, purulent discharge, and uterine/rectal tenderness 2
• Do not perform incomplete colonoscopy when colorectal cancer risk factors exist (age >50, family history, alarm symptoms) 2, 1, 6
• Do not underestimate bleeding in anticoagulated patients—they require aggressive monitoring for complications including intramural hematoma and perforation 4

Follow-up and Prevention

• For variceal bleeding: continued non-selective beta-blockers for prevention of recurrent bleeding 3
• Optimal management of underlying liver disease and portal hypertension 3
• Strict clinical monitoring, especially in extraperitoneal rectal bleeding where perforation may be identified late 4

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