How to manage a patient with no comorbidities or allergies, presenting with 3 episodes of hematochezia (passage of fresh blood per rectum) and 5 episodes of loose stools?

Management of Hematochezia with Loose Stools

This patient requires immediate hemodynamic assessment, risk stratification using the Oakland score, and urgent colonoscopy within 24 hours if admitted, with concurrent stool studies to evaluate for infectious causes given the diarrheal component. 1, 2, 3

Immediate Assessment and Stabilization

Perform hemodynamic evaluation first:

• Check vital signs immediately including heart rate, blood pressure, and assess for signs of hypovolemia or shock 2
• Obtain complete blood count, coagulation parameters, blood urea nitrogen, creatinine, and serum electrolytes 1, 2
• Perform blood typing and cross-matching given multiple episodes of hematochezia 2
• Establish two large-bore IV lines if any signs of hemodynamic instability 1, 2

Apply the Oakland Score for risk stratification:

• Calculate the Oakland score to determine if this is a major bleed (>8 points) requiring hospital admission or minor bleed (≤8 points) suitable for outpatient management 2
• Patients scoring >8 points require inpatient management with urgent colonoscopy 2
• Patients scoring ≤8 points with no other indications can be safely discharged for urgent outpatient investigation 2

Diagnostic Workup

Obtain comprehensive stool studies given the diarrheal component:

• Send stool culture for bacterial pathogens (Salmonella, Shigella, Campylobacter, E. coli O157:H7) 4, 3
• Order Clostridium difficile toxin assay 3
• Consider fecal calprotectin to evaluate for inflammatory bowel disease 3
• The combination of hematochezia with loose stools suggests either infectious colitis or inflammatory bowel disease as leading differential diagnoses 3

Proceed with colonoscopy as primary diagnostic modality:

• Perform urgent colonoscopy within 24 hours after hemodynamic stabilization if admitted 1, 2, 3
• Ensure thorough bowel preparation despite active bleeding to improve diagnostic yield (72-86%) 1, 3
• Consider upper endoscopy first to exclude an upper GI source, as 10-15% of patients with severe hematochezia have an upper GI bleeding source 4, 1

Common pitfall: Do not delay colonoscopy due to concerns about bowel preparation—adequate preparation is essential even with active bleeding to ensure accurate diagnosis 1

Management Based on Findings

If infectious colitis is identified:

• Most cases are self-limited and require only supportive care 4
• Provide IV fluids and electrolyte replacement if dehydration is present 3
• Consider empiric antibiotics only if C. difficile is suspected (metronidazole or fluoroquinolone) 3
• Avoid antidiarrheal agents like loperamide in bloody diarrhea or suspected infectious colitis, as this may worsen outcomes 5

If inflammatory bowel disease is suspected:

• Establish gastroenterology follow-up for long-term management 3
• Colonoscopy will reveal friable, ulcerated mucosa with continuous inflammation in ulcerative colitis 3

If no source is identified on initial colonoscopy:

• Perform repeat colonoscopy with thorough bowel preparation if initial prep was inadequate 1
• Consider CT angiography if hemodynamically unstable with suspected active bleeding 1, 2
• Consider small bowel evaluation with capsule endoscopy or CT/MR enterography if no colonic source identified 3

Resuscitation for Severe Bleeding (if applicable)

If hemodynamically unstable:

• Begin crystalloid infusion targeting mean arterial pressure >65 mmHg 1, 2
• Maintain hemoglobin >7 g/dL while avoiding fluid overload 1, 2
• Correct any coagulopathy before invasive procedures 1

Critical pitfall: Avoid over-transfusion, which may increase portal pressure and potentially worsen bleeding if portal hypertension is present 1

Follow-up and Monitoring

• Monitor hemoglobin weekly until stable, then monthly for 3 months 3
• Clinical improvement in infectious diarrhea is usually observed within 48 hours 5
• Arrange gastroenterology follow-up for surveillance colonoscopy if IBD is diagnosed 3