LEARNING OBJECTIVE
After this activity, the participant will be able to differentiate management strategies for varying presentations of acute lower gastrointestinal bleeding (LGIB).
QUESTION 1
A 76-year-old man with a history of diverticulosis and atrial fibrillation on rivaroxaban presents to the emergency department (ED) at a tertiary care hospital after developing large volume painless hematochezia. He continued to pass bright red blood and blood clots per rectum since arrival at the ED. At the time of evaluation, the patient's heart rate is 115 beats per minute and blood pressure is 85/55 mm Hg despite 2 L of crystalloid fluid and 2 units of packed red blood cell transfusion. Laboratory test results are notable for hemoglobin of 6.5 gm/dL, platelets of 260,000/µL, blood urea nitrogen (BUN) of 15 mg/dL, and serum creatinine of 1.3 mg/dL.
In addition to ongoing resuscitation, what is the best next step in management?
- A. Perform esophagogastroduodenoscopy (EGD)
- B. Obtain nasogastric aspirate
- C. Order computed tomography (CT) angiography
- D. Plan for urgent colonoscopy
QUESTION 2
A 55-year-old woman with a history of systemic lupus erythematosus, end-stage renal disease on intermittent hemodialysis, idiopathic thrombocytopenic purpura (ITP), and recent pulmonary embolism on warfarin presented to the ED for painless hematochezia. After intravenous fluid resuscitation, her heart rate is 75 beats per minute, and blood pressure is 122/74 mm Hg. Laboratory test results include hemoglobin of 8.5 g/dL, platelets of 65,000/µL, and international normalized ratio (INR) of 2.4. A bowel preparation is ordered, and the patient is scheduled to undergo a colonoscopy to further evaluate the cause of LGIB.
What is the best next step in this patient's management?
- A. Four-factor prothrombin complex concentrate (PCC)
- B. Colonoscopy
- C. Platelet transfusion
- D. Tranexamic acid
QUESTION 3
Which of the following is true regarding the use of direct oral anticoagulants (DOACs) and LGIB?
- A. DOACs have been shown to increase the risk of new onset diverticular hemorrhage
- B. Combinations of antiplatelet and DOACs are not associated with an increased risk of LGIB compared to DOAC use alone
- C. There is a decreased risk of LGIB between DOACs when compared to warfarin
- D. Patients with new-onset LGIB after starting a DOACs are more likely to subsequently be diagnosed with colorectal cancer
