WK 6 Steve Morris – GI Bleed 73 Y/O C/O RECTAL BLEEDING (ASSURED A)
This is a 73 year-old with a past medical history significant for hypertension, atrial- fibrillation
(Warfarin 2.5 mg daily), hyperlipidemia, BPH, an
...
WK 6 Steve Morris – GI Bleed 73 Y/O C/O RECTAL BLEEDING (ASSURED A)
This is a 73 year-old with a past medical history significant for hypertension, atrial- fibrillation
(Warfarin 2.5 mg daily), hyperlipidemia, BPH, and s/p cholecystectomy some years ago. He
presents this morning with the chief complaint of a sudden-onset of bright red bowel movements
without any associated abdominal or rectal pain beginning approximately 15 hours ago after
diner-time last night. When asked how much blood his response was, “not enough to make the
water in the toilet bowel turn dark red.” He also states this has never happened before. Also, over
the past 3 months, despite not having changed his diet or activity level, he has lost approximately
10 pounds.
This is a 73 year-old with a PMH: HTN, AFIB (warfarin), hyperlipidemia, and BPH. He
presents this morning with the chief complaint of a sudden-onset of bright red bowel movements
without any associated abdominal or rectal pain beginning approximately 15 hours ago after
diner-time last night. PE revealed: conjuctival-rim pallor, diminished DP-pulses, hypertensionwide-pressure, orthostatic-hypotension, hyperactive-bowel-sounds, mild-tenderness-with-deeplower-quad-palpation, bright-red blood visible at the orifice of rectum, appox-6-bloody-BMover-15hours
Primary Diagnosis: Diverticula Hemorrhage Secondary Diagnosis: Diverticulosis Third
Diagnosis: Severe Hypertension
Colonic diverticular bleeding is one of the common causes of lower gastrointestinal hemorrhage
(Porter, Kaplan, & Lynn, 2018). Though the bleeding ceases spontaneously in most patients, lifethreatening hemorrhage is not uncommon (Ramai, Ofosu, & Reddy, 2018). Patients with
clinically suspected diverticular hemorrhage should be admitted to hospital (Labenz, 2014).
However, Although I would not admit for his hypertension alone coupled with acute lower GI
bleed on Warfarin therapy increases his risk of rebleed or ongoing bleed, which justifies
admission. Current American Society for Gastrointestinal Endoscopy (ASGE) guidelines
recommend “early” colonoscopy for management of LGIB. Given the increased risk of early
rebleeding (warfarin therapy) associated with the presence of active bleeding seen during the
colonoscopy (iHuman), identification of the appropriate endoscopic intervention is crucial.
Endoscopic interventions include: injection of epinephrine, heat cautery, clip placement, and
ligation (Rustagi & McCarty, 2014). Epinephrine injection often provides only temporary
cessation of hemorrhage with significant risk of early rebleeding within 30 days. For this reason,
the injection is traditionally combined with endoscopic hemostatic clipping. Treatment of colonic
diverticular bleeding using hemostatic clips with no immediate or recurrent bleeding the
endoclips are placed adjacent to the visible site of bleeding and then closed allowing for
occlusion of vessel to achieve hemostasis. These clips typically fall off after some time,
theoretically after hemostasis has been obtained and cessation of bleeding is achieved; however,
given the pathophysiology of diverticular bleeding, thinning of the mucosa and poor segmental
integrity of the vessel may lead to ineffective long term hemostasis by simple clipping (Rustagi
& McCarty, 2014). Given this significant risk of long-term rebleeding, indirect placement of
hemoclips in ascending lesions is ineffective and should not be considered first-line for
endoscopic treatment of diverticular bleeding (Rustagi & McCarty, 2014). Although multipolar
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