Aamer Agha, MD Series Editor: Richard Goodgame, MD


June 07, 2006

Case Presentation

An 83-year-old woman presented to clinic with 3 hours of massive rectal bleeding.

She had the abrupt onset of passing a large amount of red blood with clots from the rectum. There was no normal stool. One hour later, she passed another large amount of red blood with clots. She began to experience dizziness and unsteady gait. The gastrointestinal review of symptoms was otherwise negative. She had had no abdominal pain, weight loss, or change in bowel function. She had never undergone colon cancer screening.

She was previously well with no prior medical conditions, chronic medications, or prior hospitalizations except for a hysterectomy 40 years ago. She has had no excessive alcohol or tobacco use, no substance abuse, no recent travel, and there is no relevant family history of serious illness.

Physical examination revealed the following vital signs: blood pressure, 105/70 lying, 95/69 standing; heart rate, 95 beats per minute (bpm) lying, 101 bpm standing; respiratory rate, 16 breaths per minute; temperature, 98.6°F. She was awake, alert, and calm. The skin and extremities were normal. There was no jaundice or stigmata of chronic liver disease. The lungs were normal. The cardiac examination showed only tachycardia and a hyperdynamic circulation. There was no abdominal tenderness, mass, or organomegaly. Digital rectal examination revealed no mass or tenderness, but bright red blood coated the exam glove.

Routine laboratory studies were all normal except for initial hemoglobin level of 10.4 g/dL, which decreased to 7.8 g/dL after volume resuscitation with normal saline. Coagulation, liver chemistries, blood urea nitrogen, and creatinine levels were normal.

Nasogastric aspirate produced bile-stained gastric contents but no blood. Results of proctoscopy performed in the emergency department showed red blood but no source of bleeding. The patient was admitted to the surgical intensive care unit (ICU). She passed another large amount of red blood with clots. After 3 hours, she had received 4 units of packed red blood cells. Vital signs were normal and hemoglobin level was 8.2 g/dL.


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