In an elderly woman with massive lower gastrointestinal hemorrhage, diffuse abdominal tenderness, and ongoing hemodynamic instability despite transfusion, what is the most appropriate next step in management: fresh frozen plasma, angiography, emergent laparotomy, or emergency colonoscopy?

Emergency Laparotomy is Indicated

In an elderly woman with massive lower GI bleeding, diffuse abdominal tenderness, and persistent hemodynamic instability despite transfusion, proceed directly to emergency laparotomy (Option C). Diffuse abdominal tenderness with lower GI bleeding indicates bowel ischemia, infarction, or perforation—conditions that carry near-certain mortality without immediate surgical intervention. 1

Critical Recognition: Peritoneal Signs = Surgical Emergency

• Peritoneal signs with lower GI bleeding suggest transmural bowel pathology (ischemia, infarction, or perforation) that requires urgent surgery due to otherwise prohibitively high mortality rates. 1
• The British Society of Gastroenterology explicitly acknowledges "exceptional circumstances" where proceeding directly to surgery is justified, specifically mentioning conditions like aortoenteric fistula and, by extension, any condition suggesting bowel catastrophe. 2, 1
• The presence of lower-GI bleeding together with diffuse abdominal tenderness constitutes an "exceptional circumstance" in which laparotomy without prior lesion localization is justified. 1

Why NOT the Other Options

Option A: Fresh Frozen Plasma (FFP) - Wrong Priority

• FFP is only supportive care for coagulopathy and does not address a surgical abdomen; its use delays definitive surgery. 1
• FFP should be given for INR >1.5, but this is an adjunct to surgery, not an alternative. 3
• For warfarin reversal in unstable hemorrhage, prothrombin complex concentrate (PCC) plus vitamin K is superior to FFP and provides rapid correction within minutes. 1, 3
• In this patient with peritoneal signs, correcting coagulopathy while preparing for laparotomy is appropriate, but FFP alone is not definitive management. 1

Option B: Angiography - Contraindicated by Peritoneal Signs

• Angiography is indicated for hemodynamically unstable patients WITHOUT peritoneal signs. 1, 3
• CT angiography followed by catheter embolization is the correct pathway for unstable lower GI bleeding when the abdomen is soft and non-tender. 2, 3
• Do NOT postpone laparotomy to obtain imaging (CT angiography, catheter embolisation) or endoscopy when peritoneal signs are present; delay markedly increases mortality from untreated bowel infarction or perforation. 1
• The British Society of Gastroenterology states that no patient should proceed to emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities, EXCEPT under exceptional circumstances. 2, 1

Option D: Emergency Colonoscopy - Absolutely Contraindicated

• Colonoscopy is explicitly contraindicated in hemodynamically unstable patients (shock index >1) and in any patient with peritoneal signs. 2, 3
• Colonoscopy requires 4-6 L of polyethylene glycol bowel preparation over 3-4 hours, which is not feasible in an actively bleeding, unstable patient. 3
• Colonoscopy is reserved for hemodynamically stable patients without peritoneal signs and should not be used as the initial diagnostic or therapeutic step in unstable cases. 1
• Urgent colonoscopy within 24 hours does NOT reduce rebleeding, mortality, or length of stay compared with elective colonoscopy after stabilization. 2, 3

Surgical Approach and Concurrent Management

Immediate Resuscitation While Preparing for Surgery

• Continue aggressive volume resuscitation with crystalloid and packed red blood cells while preparing for laparotomy. 1
• Use restrictive transfusion thresholds: hemoglobin trigger ≈70 g/L for patients without cardiovascular disease, ≈80 g/L for those with cardiovascular disease. 3
• Correct coagulopathy with prothrombin complex concentrate and vitamin K if anticoagulated (superior to FFP for rapid reversal). 1, 3
• Transfuse platelets when platelet count is <50 × 10⁹/L. 3

Intraoperative Considerations

• The operation should be led by colorectal surgeons capable of performing on-table colonoscopy to aid localisation and determine the extent of resection when needed. 1
• On-table colonoscopy should be performed by colorectal surgeons if feasible to attempt localization and guide the extent of resection. 1
• For sigmoid volvulus with ischemia (one possible cause of this presentation), resection of infarcted bowel should be performed without detorsion and with minimal manipulation to prevent release of endotoxin, potassium and bacteria. 2

Mortality Context and Evidence Strength

• The mortality rate for emergency surgery in lower GI bleeding is 10% overall, but this must be weighed against near-certain mortality from untreated bowel infarction or perforation. 1
• Emergency subtotal colectomy has significant morbidity and mortality, but is life-saving when indicated. 1
• Blind segmental resection without prior localization carries rebleeding rates up to 33% and mortality 33-57%, but when peritoneal signs are present, the alternative is death from untreated perforation or infarction. 3, 4

Critical Pitfall to Avoid

Do NOT assume that all unstable lower-GI bleeding requires localization first; the presence of peritoneal signs or an aorto-enteric fistula mandates immediate surgical exploration. 1 The standard algorithm of CTA → angiography → surgery applies only to patients with a soft, non-tender abdomen. 1, 3