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

Emergency Laparotomy is Indicated

For an unstable elderly woman with severe lower GI bleeding, diffuse abdominal tenderness, and persistent hemodynamic instability despite blood transfusion, proceed immediately to emergency laparotomy (Option C). The diffuse abdominal tenderness represents a surgical abdomen indicating bowel catastrophe—likely ischemia, infarction, or perforation—not simply a bleeding problem 1.

Critical Decision Point: Recognizing the Surgical Abdomen

The combination of peritoneal signs (diffuse tenderness) with lower GI bleeding and hemodynamic instability despite resuscitation represents one of the "exceptional circumstances" where proceeding directly to surgery is justified 1. This clinical picture suggests:

• Bowel ischemia or infarction with extremely high mortality without immediate surgical intervention 1
• Fulminant colonic ischemia, particularly dangerous in elderly patients, requiring urgent surgery 1
• Possible bowel perforation or aortoenteric fistula 1

Why Not the Other Options?

Angiography (Option B) - Wrong in This Context

• While CT angiography is typically the first-line diagnostic approach for unstable lower GI bleeding 2, 3, this recommendation applies to patients without peritoneal signs 2
• The standard algorithm (CTA → catheter angiography with embolization) is appropriate for isolated bleeding, not surgical abdomen 2, 3
• 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

Emergency Colonoscopy (Option D) - Contraindicated

• The British Society of Gastroenterology explicitly recommends against colonoscopy when patients have shock index >1 or remain unstable after resuscitation 3
• Colonoscopy is reserved for stable patients or after successful localization and stabilization 3

FFP (Option A) - Insufficient Alone

• While correcting coagulopathy with prothrombin complex concentrate and vitamin K is important 1, and FFP may be needed if INR >1.5 3, this addresses only the coagulopathy, not the underlying surgical emergency
• FFP administration should occur concurrently with preparation for surgery, not as the primary intervention 1

The Exception to "Localize First"

The British Society of Gastroenterology states: "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. Your patient meets these exceptional circumstances:

• Peritoneal signs suggesting bowel catastrophe 1
• Hemodynamic instability persisting despite aggressive resuscitation 1
• Clinical picture consistent with conditions requiring immediate surgery (ischemia, infarction, perforation) 1

Concurrent Management During Surgical Preparation

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 in elderly) 1
• Correct coagulopathy with prothrombin complex concentrate and vitamin K if anticoagulated 1
• On-table colonoscopy should be performed by colorectal surgeons if feasible to attempt localization and guide extent of resection 1

Mortality Context

• Emergency surgery for lower GI bleeding carries 10% overall mortality 1
• However, failing to operate on bowel ischemia/infarction carries prohibitively high mortality 1
• The mortality rate rises to 20% in patients requiring ≥4 units of red cells 3, and your patient is already unstable despite transfusion

Critical Pitfall to Avoid

Do not delay surgery to pursue imaging or endoscopy when peritoneal signs are present with hemodynamic instability despite resuscitation 1. The diffuse abdominal tenderness fundamentally changes the management algorithm from a bleeding problem to a surgical emergency 1.