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A D V E R T I S E M E N T
A D V E R T I S E M E N T
A 74-year-old male presented with a history of passing large amounts of bright red blood per rectum. He had one previous episode four years before that required hospitalization and stopped spontaneously. No source of bleeding was documented on that admission. It used to be taught that the majority of GI bleeds were from an upper source, but with the widespread use of H2 blockers and proton pump inhibitors, the prevalence of upper GI bleeds is decreasing.
A D V E R T I S E M E N T
The patient was taken to the ICU for resusciation. The bleeding stopped after initial transfusion of two units. Although there was no blood returned on NG aspirate, upper endoscopy was performed first. The examination showed no bleeding site in stomach or duodenum. Flexible sigmoidoscopy revealed dark blood in the rectum with no active source of bleeding.
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A D V E R T I S E M E N T
After 12 hours, the patient again began putting out large quantities of bright red blood. Because of the rate of bleeding, angiogram rather than bleeding scan was then performed. Preliminary bleeding scan is preferred before angiogram because it is more sensitive (detects bleeds as slow as 0.1cc/min v. 1.0cc/min for angiogram) and because it localizes the general area, decreasing the number of vessels needing study on subsequent interventional angiography. Lowering the contrast load reduces the chance of nephrotoxicity.
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