In a 78‑year‑old man who recently underwent colonoscopy and now has decreased hematocrit and hemoglobin, low serum calcium, low total protein, and low albumin, what is the most urgent problem and how should it be managed?

Post-Colonoscopy Anemia with Hypoalbuminemia in a 78-Year-Old Man

The most urgent problem is post-procedural bleeding causing anemia, which must be evaluated immediately with hemodynamic assessment and urgent colonoscopy if the patient is stable, or CT angiography if unstable.

Immediate Assessment of Bleeding Severity

Calculate the shock index (heart rate ÷ systolic blood pressure) immediately to determine hemodynamic stability; a shock index >1 indicates instability and mandates CT angiography rather than colonoscopy. 1

• Obtain vital signs, complete blood count, coagulation profile (PT/INR), and blood type with cross-match immediately. 1, 2
• Perform digital rectal examination to confirm active bleeding and assess for anorectal pathology. 1
• Check for orthostatic hypotension, which indicates significant blood loss requiring ICU admission. 1

Management Algorithm Based on Hemodynamic Status

If Hemodynamically Unstable (Shock Index >1)

Perform CT angiography immediately as the first diagnostic test—NOT colonoscopy—because CTA provides the fastest, least invasive means to localize bleeding with 94% sensitivity and can detect bleeding rates as low as 0.3 mL/min. 1

• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes to maximize success rates. 1
• Correct coagulopathy immediately: transfuse fresh frozen plasma for INR >1.5 and platelets for platelet count <50,000/µL. 1
• Use restrictive transfusion thresholds: hemoglobin trigger 70 g/L (target 70-90 g/L) for patients without cardiovascular disease, or 80 g/L (target 100 g/L) for those with cardiovascular disease. 1
• If CTA shows no lower GI source, perform upper endoscopy because 10-15% of severe hematochezia originates from the upper GI tract. 1, 2

If Hemodynamically Stable (Shock Index ≤1)

Calculate the Oakland score (incorporating age, gender, previous lower GI bleeding admission, digital rectal examination findings, heart rate, systolic blood pressure, and hemoglobin) to guide management. 1

• Oakland score >8 points: Admit for inpatient colonoscopy on the next available list (not urgently within 24 hours, as urgent colonoscopy does not improve rebleeding, mortality, or length of stay). 1
• Ensure adequate bowel preparation with 4-6 L polyethylene glycol over 3-4 hours before colonoscopy, as poor preparation leads to missed lesions and repeat procedures. 1
• Colonoscopy achieves diagnostic accuracy of 72-86% and allows therapeutic intervention for post-polypectomy bleeding sites. 1, 2

Addressing the Hypoalbuminemia and Hypocalcemia

Corrected Calcium Calculation

The reported total calcium of 8.2 mg/dL must be corrected for the low albumin of 3.7 g/dL, because hypoalbuminemia increases the calcium-binding ratio per gram of albumin, and conventional correction formulas using a fixed binding ratio of 0.88 mg calcium/g albumin lead to major errors. 3

• In hypoalbuminemia, calcium binding increases from 1.0 to 2.1 mg calcium/g albumin as albumin decreases from 3.1 to 1.7 g/dL. 3
• Measure ionized calcium directly rather than relying on corrected total calcium, because corrected values may falsely suggest normocalcemia when ionized calcium is actually low. 3

Calcium Replacement if Ionized Calcium is Low

If ionized calcium is <0.9 mmol/L (or total corrected calcium <7.5 mg/dL), administer calcium chloride 10 mL of 10% solution (270 mg elemental calcium) rather than calcium gluconate, because calcium chloride is preferred when liver function may be impaired. 4

• Ionized calcium <0.8 mmol/L is associated with cardiac dysrhythmias and must be corrected promptly. 4
• Calcium is essential for coagulation cascade function (cofactor for factors II, VII, IX, X) and platelet adhesion at vessel injury sites. 4

Hypoalbuminemia Management

The low albumin (3.7 g/dL) and total protein (5.7 g/dL) likely reflect acute blood loss and hemodilution from resuscitation rather than chronic malnutrition, given the post-colonoscopy timing. 4

• Albumin is an acute-phase protein that decreases during active bleeding and inflammation; it is not an appropriate marker of malnutrition or malabsorption. 4
• Do not routinely administer albumin infusions for mild hypoalbuminemia (3.7 g/dL) in the absence of circulatory shock or massive fluid shifts, as albumin replacement is indicated primarily for hypovolemic shock, severe burns >24 hours, or cirrhotic ascites removal. 5

Post-Polypectomy Bleeding Considerations

Post-polypectomy bleeding occurs in up to 2.5% of colonoscopies, with the majority of significant bleeds following polypectomy; delayed bleeding can occur up to 15 days post-procedure but resolves spontaneously in >70% of cases. 4, 1

• Early bleeding (at time of polypectomy) can be controlled by re-snaring the stalk and applying direct pressure. 1
• Persistent delayed bleeding may be treated with loop or band ligation, adrenaline injection followed by thermal therapy, or endoscopic clipping. 1

Common Pitfalls to Avoid

• Do not rush to colonoscopy in unstable patients—this delays definitive CTA localization and potential embolization. 1
• Do not use conventional albumin correction formulas for calcium in hypoalbuminemia—measure ionized calcium directly. 3
• Do not perform colonoscopy without adequate bowel preparation—inadequate prep leads to missed lesions and repeat procedures. 1
• Do not assume the low albumin requires albumin infusion—it likely reflects acute blood loss and hemodilution, not chronic protein depletion. 4, 5
• Do not delay resuscitation to perform diagnostic procedures—stabilization takes priority. 2