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Old 09-29-2012
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Arrow Gyrus Daily Questions; Internal Medicine #41

A 69-year-old patient presents to the emergency department with hematochezia of 4 h duration. The pa-tient is pale but alert and oriented. Blood pressure is 107/ 82 mmHg, respiratory rate is 24 breaths/min and heart rate is 96 beats/min. The hematocrit is 24%, with a base-line of 32%. Which of the following represents the best ap-proach for localization of this patient’s intestinal bleeding?
A. Angiography is most appropriate for this massive gastrointestinal (GI) bleed.
B. Angiography is of little utility since the patient is not stable.
C. Colonoscopy is better suited to localize bleeding, if it is massive.
D. Colonoscopy can be diagnostic and therapeutic in this mild GI bleed.
E. Immediate surgery with intraoperative localization is appropriate.
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A. Angiography is most appropriate for this massive gastrointestinal (GI) bleed...??????
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Originally Posted by cingulate.gyrus View Post
A 69-year-old patient presents to the emergency department with hematochezia of 4 h duration. The pa-tient is pale but alert and oriented. Blood pressure is 107/ 82 mmHg, respiratory rate is 24 breaths/min and heart rate is 96 beats/min. The hematocrit is 24%, with a base-line of 32%. Which of the following represents the best ap-proach for localization of this patient’s intestinal bleeding?
A. Angiography is most appropriate for this massive gastrointestinal (GI) bleed.
B. Angiography is of little utility since the patient is not stable.
C. Colonoscopy is better suited to localize bleeding, if it is massive.
D. Colonoscopy can be diagnostic and therapeutic in this mild GI bleed.
E. Immediate surgery with intraoperative localization is appropriate.
D. Colonoscopy can be diagnostic and therapeutic in this mild GI bleed.
Based on his age it is most likely to be a diverticular bleed.
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Quote:
Originally Posted by K06100 View Post
A. Angiography is most appropriate for this massive gastrointestinal (GI) bleed...??????


Quote:
Originally Posted by Novobiocin View Post
D. Colonoscopy can be diagnostic and therapeutic in this mild GI bleed.
Based on his age it is most likely to be a diverticular bleed.

I Know its controversial but the answer given is



The answer is A. Angiography is most appropriate for this massive
gastrointestinal (GI) bleed

Reference is Harrison's test book 18 edition p2502.

Hemorrhage from a colonic diverticulum is the most common cause of hematochezia in patients >60 years of age. Patients with atherosclerosis, hypertension, and increased bleeding risk are most commonly affected. Most bleeds are intense, but are self-limited and stop spontaneously. They usually arise from the right colon. The lifetime risk of rebleeding is 25%.

While colonoscopy can be both diagnostic and therapeutic in lower GI bleeding, the ability to visualize the mucosa is limited when the bleeding is brisk.

Angiography can localize the bleeding and, if the patient is stable, bleeding
is best managed by mesenteric angiography. If identified, the bleeding vessel may be successfully occluded with a coil in 80% of cases with <10% risk of colonic ischemia.

This patient is normotensive and has a normal heart rate, suggesting that he is stable for angiography. Surgery is reserved for patients with unstable bleeding or a >6 unit/24 h bleeding episode.
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Which of the following represents the best approach for localization of this patient’s intestinal bleeding?
This is a poorly worded question since the question is asking about this patient who is not massively bleeding (as "This patient is normotensive and has a normal heart rate").

I would. however, agree that my answer was wrong since a diverticular bleed should not be managed with colonoscopy therapeutically and choice A seems to be the only viable option provided they have clarified the "massive" bleed in a better way.
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