Bloody diarrhoea

Question 1

You are bleeped to see an 82 year old lady with significant PR bleeding in A&E. She usually lives in a nursing home and presents with a three day history of bloody diarrhoea. Her only past medical history is atrial fibrillation.

Her observations are:

Respiratory rate 25 breaths per minute
Oxygen saturations 93% on air
Blood pressure 110/65
Heart Rate **100 **bpm
Temperature 37.5 degrees Celsius

How would you assess the patient?

Answer 1

ABCDE approach (tachypnoeic, tachycardiac, BP stable)

A
* Ensure patent airways, if alert and talking, can be assumed

B
- Monitor SpO2, RR
- Give supplemental high flow O2 via NRB
- Look, listen and feel the chest

C
- Monitor HR, BP
- Check CRT peripherally and centrally
- 12-lead ECG / ECG monitor
- 2 x large bore IV access - take bloods at the same time
- Check fluid status (JVP, oedema)
- Give IV crystalloid boluses (given her age, would do 250 ml boluses)
- Insert catheter to monitor UO
- Check peripheral pulses

D
- Check temperature, blood glucose
- AVPU / GCS

E
- Examine thoroughly including an abdominal examination

Question 2

What are the likely causes of her symptoms?

Best split into Local and systemic

Answer 2

Local
* Haemorrhoids
* Anal fissures
* Fistulas

More proximal can be divided according to their underlying aetiology
Infective: gastroenteritis
Neoplastic: anal cancer, colorectal
Vascular: mesenteric ischaemia
Inflammatory: diverticulitis, Crohn’s disease, ulcerative colitis

Give the patient’s age and her history of AF, I am immediately concerned about mesenteric ischaemia.

Question 3

What else would you like to know from the history?

Answer 3

Detailed Hx of the presenting complaint
* Onset
* Nature (colour, volume etc)

How has she been recently?
- Recent infection
- Weight loss
- Fever, lethargy
- Any previous similar episodes?
- Infective contacts with other residents?
- Recent antibiotics?

PMHx:
- Ask specifically about GI conditions (IBD, diverticulitis)
- Anticoagulants / antiplatelets

FHx of clotting disoders / GI conditions

SHx - smoking, alcohol, diet/lifestyle, functional status - would be important re- her ceiling of care

Quick systematic review

Question 4

What further investigations would you like?

Answer 4

Bedside
- Monitor SpO2, give high flow O2
- Monitor HR, BP
- 12-lead ECG
- Digital rectal examination
- Quick VBG/ABG - lactate, Hb, glucose

Bloods
- FBC, CRP, U&E, LFTs
- INR, Coagulation screen
- G&S

Imaging
- Abdominal X ray (if concerned about obsrtuction / toxic megacolon)
- Erect CXR for signs of visceral perforation
- CT angiogram as per BSG if active bleeding is suspected in patients who have been stabilised - would discuss with senior

Question 5

Her ABG results are now available:
pH 7.28, PaO2 10.5, PaCO2 4, Bicarbonate 15, BE -4, Lactate 4.5.

How would you manage her?

Answer 5

The ABG shows metabolic acidosis with partial respiratory compensation due to her lactate being very high.

This shows signs of hypoperfusion

The patient needs aggressive fluid resuscitation +/- blood transfusion if Hb low

Depending on the body habitus of the patient, I would start with either 250 mL or 500 mL crystalloid boluses (0.9% NaCL)

Reassess

Repeat if necessary

Question 6

Who else would you involve?

Answer 6

In the first instance I would inform my registrar and ask her to come and review her.

Given how unwell she is, she would be better managed in resus, which may involve a discussion with the ED consultant in charge.

Question 7

You now have one minute to handover the patient in this scenario to your registrar / consultant as if you were at the Acute Medical Handover.

Answer 7

Situation: I am concerned about this 82 year old lady with a raised lactate and metabolic acidosis secondary to hypoperfusion as a result of a significant PR-bleed.

Background: She has a history of persistent pr-bleeding and is also known to have AF. Her drug history is not known.

Assessment: Fluid resuscitation has been started and a group and save ad crossmatch has been urgently sent to the lab. She is tachycardiac and hypotensive.

Recommendations: I am worried that this patient could quickly deteriorate. I have recommended that she is moved to the Resus department in A+E where she can be closely monitored. She needs an urgent senior review. I have asked the team to urgently request her drug history from the nursing home. If she is on anticoagulation for her AF she may need a reversal agent or discussion with haematology. In the event of a further deterioration she should be given O-negative blood from the transfusion fridge pending her formal cross-matched sample.