What should I do for rectal bleeding accompanied by dizziness?

Rectal Bleeding with Dizziness: Emergency Management

Rectal bleeding accompanied by dizziness indicates hemodynamic compromise requiring immediate emergency department transfer for resuscitation and urgent evaluation. 1

Immediate Recognition and Transfer to Emergency Department

Dizziness with rectal bleeding signals potential hypovolemia or shock, which mandates immediate ER transfer. 1 The presence of hemodynamic instability—including hypotension, tachycardia, or altered mental status—requires emergency evaluation. 1

Key indicators that this patient needs immediate ER transfer include:

• Mean arterial pressure <65 mmHg 1
• Shock index >1 (heart rate divided by systolic blood pressure) 1
• Signs of active, brisk bleeding with hemodynamic changes 1
• Orthostatic vital sign changes suggesting volume depletion 1

Initial Emergency Department Management

Resuscitation Protocol

The priority is immediate hemodynamic stabilization before diagnostic procedures. 2

• Establish two large-bore IV lines for rapid fluid and blood product administration 2
• Begin crystalloid infusion targeting mean arterial pressure >65 mmHg while avoiding fluid overload 2
• Check vital signs, hemoglobin, hematocrit, and coagulation parameters to evaluate bleeding severity 3
• Obtain blood typing and cross-matching for severe bleeding 3
• Maintain hemoglobin level >7 g/dL during resuscitation phase 3, 2

Risk Stratification

Calculate the Oakland score to determine urgency of investigation and disposition. 2

• Oakland score >8 points: Admit for inpatient management with urgent colonoscopy within 24 hours 2
• Oakland score ≤8 points: Can be safely discharged for urgent outpatient investigation within 2 weeks if hemodynamically stable 2

Given that this patient presents with dizziness, they likely have a higher Oakland score and will require admission. 2

Diagnostic Approach

Critical Pitfall to Avoid

Do not assume the bleeding source is lower GI based on rectal bleeding alone. Up to 10-15% of patients with severe hematochezia have an upper GI source. 2, 4 Even in patients with known diverticulosis and hematochezia, up to 8% have an upper GI bleeding source. 2

Recommended Diagnostic Sequence

• Perform colonoscopy within 24 hours after hemodynamic stabilization for major bleeds 2
• Ensure adequate bowel preparation with polyethylene glycol solutions to improve mucosal visualization and diagnostic yield 2
• Use ano-proctoscopy or flexible sigmoidoscopy as first-line diagnostic tools if anorectal varices are suspected 3
• Perform urgent colonoscopy (plus upper endoscopy) within 24 hours for patients with high-risk features or ongoing bleeding 3

Special Considerations Based on Etiology

If Portal Hypertension or Liver Disease Present

Suspect anorectal varices and initiate multidisciplinary management early involving hepatology. 2

Specific management for bleeding anorectal varices:

• Use vasoactive drugs such as terlipressin or octreotide to reduce splanchnic blood flow and portal pressure 3, 2
• Administer a short course of prophylactic antibiotics 3
• Temporarily suspend beta-blockers during acute bleeding 3
• Consider endoscopic band ligation, sclerotherapy, or EUS-guided glue injection as first-line treatment where feasible 5
• Consider TIPS (transjugular intrahepatic portosystemic shunt) to decompress the portal venous system in patients with severe portal hypertension if not contraindicated 5, 2

If Diverticular Bleeding Suspected

Diverticulosis accounts for 25-30% of severe lower GI bleeding and typically presents with massive, painless rectal hemorrhage. 5, 6 Approximately 80% of diverticular hemorrhage resolves spontaneously. 6

Management approach:

• Colonoscopy within 12-48 hours after rapid bowel preparation is the recommended initial diagnostic test 6
• Endoscopic therapeutic maneuvers include epinephrine injection or electrocautery therapy 6
• If bleeding source not identified, perform radionuclide imaging followed by arteriography 6

High-Risk Features Requiring Intensive Monitoring

Patients with the following features should be admitted to the intensive care unit: 7

• Presence of hypotension on arrival (35% vs 10% in those not requiring urgent surgery) 7
• Associated comorbidities, which significantly increase morbidity and mortality risk 7
• Need for urgent surgery 7
• Hemoglobin drop ≥1.5 g/dL from baseline 1
• Clinical need for blood transfusion 1

Common Pitfalls to Avoid

• Delaying resuscitation to perform diagnostic procedures: Stabilization takes priority over diagnosis 2
• Inadequate bowel preparation: This leads to poor visualization during colonoscopy and missed diagnoses 2
• Over-transfusion: May increase portal pressure and potentially worsen bleeding in patients with portal hypertension 2
• Assuming lower GI source in severe bleeding: Always consider upper GI source, especially with hemodynamic instability 2, 4
• Premature resort to surgery: Attempt to localize bleeding through radiological and/or endoscopic modalities first 2

Prognosis and Follow-up

Morbidity is 6.4% and mortality is 4.7% in severe acute lower GI bleeding. 7 After initial management, bleeding relapses in approximately 30% of patients during long-term follow-up. 7 All patients require appropriate follow-up to ensure adequacy of treatment and for further diagnostic procedures or definitive treatment. 8