In an elderly woman with massive lower gastrointestinal bleeding, diffuse abdominal tenderness, fresh blood per rectum, and ongoing hemodynamic instability despite blood transfusion, what is the most appropriate next step in management: A) administer fresh frozen plasma, B) perform angiography, C) perform emergent laparotomy, or D) perform emergency colonoscopy?

Emergency Laparotomy is Indicated

In an elderly woman with massive lower GI bleeding, diffuse abdominal tenderness, fresh blood per rectum, and persistent hemodynamic instability despite blood transfusion, emergency laparotomy (Option C) is the most appropriate next step. The presence of diffuse abdominal tenderness with peritoneal signs in the context of ongoing hemorrhage suggests bowel ischemia, infarction, or perforation—conditions that carry near-certain mortality without immediate surgical intervention 1.

Critical Clinical Recognition

The combination of lower GI bleeding with diffuse abdominal tenderness represents an "exceptional circumstance" where proceeding directly to surgery is justified, even without prior localization. 2

• Peritoneal signs indicate transmural pathology (bowel infarction, perforation, or fulminant ischemic colitis) that requires immediate surgical exploration 1
• The British Society of Gastroenterology explicitly states that laparotomy without localization should be avoided "except under exceptional circumstances," specifically mentioning conditions like aortoenteric fistula and, by extension, any bowel catastrophe 2
• Fulminant colonic ischemia in elderly patients presents with colonic infarction and requires urgent surgery due to otherwise prohibitively high mortality 1

Why Other Options Are Inappropriate

Option A (Fresh Frozen Plasma) is Wrong

• FFP is supportive care for coagulopathy correction, not definitive management of a surgical abdomen 2, 3
• If coagulopathy exists, prothrombin complex concentrate (PCC) with vitamin K is superior to FFP for warfarin reversal in unstable hemorrhage 2, 3
• Administering FFP delays life-saving surgery and does not address the underlying surgical emergency 1

Option B (Angiography) is Wrong in This Context

• CT angiography followed by catheter embolization is the correct approach for hemodynamically unstable patients without peritoneal signs 3, 4, 5
• The presence of diffuse abdominal tenderness indicates a surgical abdomen requiring immediate exploration, not diagnostic imaging 1
• Delaying surgery for angiography in a patient with peritoneal signs and shock increases mortality from untreated bowel infarction or perforation 1

Option D (Emergency Colonoscopy) is Contraindicated

• Colonoscopy is absolutely contraindicated in hemodynamically unstable patients (shock index >1) 3, 4
• Adequate bowel preparation (4-6L polyethylene glycol over 3-4 hours) is not feasible in unstable patients 3
• Colonoscopy is reserved for stable patients without peritoneal signs 2, 4, 5
• The British Society of Gastroenterology explicitly recommends against colonoscopy as the initial approach when patients remain unstable after resuscitation 3

Surgical Approach and Concurrent Management

While preparing for immediate laparotomy:

• Continue aggressive volume resuscitation with crystalloid and packed red blood cells using restrictive thresholds (Hb trigger 70 g/L for patients without cardiovascular disease, 80 g/L with cardiovascular disease) 2, 3, 4
• Correct coagulopathy immediately: administer prothrombin complex concentrate and vitamin K for INR >1.5 if on warfarin; transfuse platelets for count <50×10⁹/L 2, 3, 4
• Surgery should ideally be performed by colorectal surgeons who can perform on-table colonoscopy to attempt localization and guide the extent of resection 2

Mortality Context and Evidence Strength

• Emergency subtotal colectomy carries mortality of 27-33%, but this must be weighed against near-certain mortality from untreated bowel infarction or perforation 1, 3
• The overall operative mortality for emergency surgery in lower GI bleeding is 10%, but proceeding to laparotomy without localization in the absence of peritoneal signs carries rebleeding rates up to 33% and mortality 33-57% 3
• The key distinction is that peritoneal signs change the risk-benefit calculation entirely—surgery becomes life-saving rather than high-risk 1

Common Pitfalls to Avoid

• Do not delay surgery to pursue imaging or endoscopy when peritoneal signs are present—this represents a surgical emergency 1
• Do not confuse the management algorithm for unstable patients without peritoneal signs (CTA → angiography) with the management of a surgical abdomen 1, 3
• Do not assume all unstable lower GI bleeding requires localization first—exceptional circumstances (peritoneal signs, aortoenteric fistula) mandate immediate surgery 2, 1