What could be causing bruising, tenderness, and diarrhea in a male patient?

Bruising with Tenderness and Diarrhea in a Male Patient

This clinical triad demands immediate evaluation for life-threatening conditions including mesenteric ischemia, neutropenic enterocolitis, and coagulopathy with gastrointestinal bleeding, prioritizing rapid assessment of hemodynamic stability and exclusion of surgical emergencies.

Immediate Risk Stratification

Calculate the shock index (heart rate ÷ systolic blood pressure) immediately upon presentation 1, 2. A shock index >1 indicates active bleeding, hemodynamic instability, and predicts need for hospital-based intervention 1, 3. Check orthostatic vital signs in stable patients, as orthostatic hypotension indicates significant blood loss requiring ICU admission 1.

Critical Red Flags Requiring Emergency Intervention

• Peritoneal signs with abdominal tenderness suggest peritonitis, perforation, or neutropenic enterocolitis requiring immediate surgical consultation 4
• Loss of rectal sensation is an ominous sign indicating transmural ischemia with nerve damage 3, 2
• Right-sided abdominal pain with bloody diarrhea is highly suggestive of non-occlusive mesenteric ischemia (NOMI) 3, 2
• Fever with neutropenia indicates potential neutropenic enterocolitis with mortality rates up to 60% if bowel wall thickness >10 mm 4
• Massive dehydration, shock, or febrile neutropenia are warning signs for potentially complicated courses 4

Initial Diagnostic Approach

Physical Examination Priorities

Assess for signs of peritoneal involvement through palpation for localized or generalized tenderness and rebound tenderness 4. Perform digital rectal examination on all patients to confirm blood in stool, detect mucus, and exclude perianal abscess formation 4, 1. Evaluate skin for petechiae, purpura, or ecchymoses suggesting coagulopathy or platelet disorders 5.

Laboratory Testing Algorithm

Obtain complete blood count with differential immediately to assess for neutropenia (absolute neutrophil count <500 cells/mL), anemia from blood loss, thrombocytopenia, or leukocytosis suggesting infection 4.

Essential initial labs include 4:

• Coagulation studies (PT, INR, aPTT) to identify bleeding disorders
• Electrolytes (potassium, sodium, calcium, magnesium) for replacement therapy
• Creatinine and urea for renal impairment assessment
• CRP and procalcitonin for infection/inflammation
• Hemoglobin for transfusion decisions

Stool studies are indicated when 4:

• Fever is present
• Neutropenia exists
• Bloody diarrhea persists >72 hours
• Recent antibiotic exposure (test for Clostridium difficile toxin)
• Recent hospitalization or healthcare exposure

Imaging Strategy

In unstable patients with peritoneal signs, obtain CT angiography immediately as the first diagnostic step 1. CT provides the fastest, least invasive means to localize bleeding and identify complications including perforation, bowel wall thickening >4 mm (suggesting neutropenic enterocolitis), pneumatosis intestinalis, or mesenteric ischemia 4, 1.

Ultrasound may identify bowel wall thickening, with thickness >10 mm associated with 60% mortality in neutropenic enterocolitis versus 4.2% with thickness ≤10 mm 4.

Critical Differential Diagnoses

Neutropenic Enterocolitis (Typhlitis)

**Suspect in any patient with neutropenia <500 cells/mL presenting with fever, abdominal pain, and diarrhea** 4. This represents a surgical emergency with mortality rates of 29.5% when pathological wall thickening is present 4. Bowel wall thickening >3-5 mm on CT is consistent with diagnosis, though C. difficile colitis can present similarly 4.

Non-Occlusive Mesenteric Ischemia (NOMI)

Consider in critically ill patients with vascular comorbidities, especially those receiving vasoconstrictive medications 3, 2. Right-sided abdominal pain with maroon or bright red blood is highly suggestive 3, 2. Loss of rectal sensation indicates transmural ischemia requiring immediate surgical consultation 2.

Chemotherapy-Induced Complications

Irinotecan causes unpredictable late diarrhea (median onset 6-14 days) with grade 3-4 rates up to 47% when combined with capecitabine 4. 5-Fluorouracil-based regimens cause diarrhea in 30-40% of patients (severe in 10-20%) 4. Disruption of gut lining permits bacterial translocation, risking overwhelming sepsis particularly when granulocyte nadir coincides with diarrhea 4.

Ischemic Colitis (Non-Neutropenic)

Docetaxel-containing regimens rarely cause ischemic colitis presenting 4-10 days post-administration with rapid onset pain, tenderness, and bloody diarrhea within 24 hours 4.

Coagulopathy with Gastrointestinal Bleeding

Normal PT and aPTT suggest platelet disorder; normal PT with prolonged aPTT indicates intrinsic pathway disorder; prolonged PT with normal aPTT suggests extrinsic pathway disorder 5. Hematologist consultation is recommended when initial evaluation indicates bleeding disorder 5.

Immediate Management

Resuscitation Protocol

Establish two large-bore IV lines immediately and begin aggressive fluid resuscitation with normal saline 1. Infuse 1-2 liters initially in hemodynamically compromised patients 1.

Transfusion thresholds 1:

• Hemoglobin trigger 70 g/L, target 70-90 g/L for clinically stable patients without cardiovascular disease
• Hemoglobin trigger 80 g/L, target 100 g/L for patients with cardiovascular disease or massive bleeding

Avoid vasopressors if possible in suspected mesenteric ischemia; use dobutamine or low-dose dopamine rather than norepinephrine if hemodynamic support required 2.

Anticoagulation Management

Interrupt warfarin immediately and reverse with prothrombin complex concentrate and vitamin K for unstable hemorrhage 1. Interrupt direct oral anticoagulants immediately and administer specific reversal agents for life-threatening hemorrhage 1.

Diarrhea Management

For uncomplicated grade 1-2 diarrhea without warning signs, initiate loperamide 4 mg followed by 2 mg every 2-4 hours (maximum 16 mg daily) 4. However, antiperistaltic agents including loperamide are contraindicated in 4, 6:

• Extremely ill patients
• Fever present
• Abdominal tenderness
• Evidence of obstruction or colonic dilation
• Suspected C. difficile infection
• Neutropenic enterocolitis

For suspected C. difficile infection with severe disease, use fidaxomicin or oral vancomycin as first-line treatment 4. Metronidazole is inferior for severe cases 4.

Surgical Indications

Immediate surgery is indicated when 1, 2:

• Hemodynamic instability persists despite aggressive resuscitation
• Blood transfusion requirement exceeds 6 units
• Peritoneal signs, pneumoperitoneum, or bowel perforation on imaging
• Portal or mesenteric venous gas on imaging (strongly suggests bowel infarction)

In neutropenic enterocolitis, surgical intervention should be reserved for selected complicated cases due to high operative mortality (27-33% for total abdominal colectomy) 4, 1.

Disposition and Follow-Up

Admit to ICU if 1:

• Shock index >1
• Orthostatic hypotension
• Neutropenia with fever
• Peritoneal signs
• Suspected mesenteric ischemia

Hematology consultation is mandatory when bleeding disorder suspected despite normal initial workup 5. Gastroenterology referral is urgent for red flag symptoms including blood in stool, weight loss, anemia, or palpable abdominal mass 7.

Common Pitfalls to Avoid

Do not delay CT angiography in unstable patients - it provides fastest diagnosis and guides intervention 1. Do not perform colonoscopy in neutropenic enterocolitis due to increased perforation risk 4. Do not use antiperistaltic agents when fever, abdominal tenderness, or severe illness present 4, 6. Do not assume upper GI source is excluded by bright red blood - massive upper GI bleeding with rapid transit can present identically 3.