Symptoms - BRBPR = hematochezia, melena -black tarry stools (probably right colon bleed or upper GI bleed), tachycardia, ?hypotension (may be massive), low CVP or PCWP readings, may have benign abdomen
DDx - Diverticulosis (most common), Angiodysplasia (usually on R side), Colon Cancer, Polyps, Ischemic Colitis, Inflammatory Bowel Disease, Hemorrhoids, Fissures, Meckel's Diverticulum, Massive UGI Bleed; Above may be exacerbated by anticoagulation (Heparin or Coumadin) or platelet dysfunction (ASA, NSAIDs, uremia, von Willebrand's disease)
Management - Maintain ABCs, O2, establish IV access (2 large gauge IVs, ?CVP line, may need SG. catheter with elderly - CHF - significant cardiac history), Foley catheter (need adequate U/O), NG tube ( ?bilious aspirate to rule out UGI source); Consider ICU transfer , Labs (CBC, platelets, PT, PTT, Fibrinogen, FDPs, Type and Cross at least 2-6 units PRBCs, Chem -7, LFT's, ABG, Ca). Blood Products prn -PRBCs, FFP, platelets, cryoprecipitate. Avoid hypotension. Keep Hematocrit > 30% in elderly. Rule out MI prn especially with hypotension in elderly
Work-Up - (need to ID site of bleed) -Digital Rectal Exam (rule out mass lesion), Anoscopy (hemorrhoids, fissures), Rigid Sigmoidoscopy (at bedside, ?rectal or sigmoid lesion identifiable), Bleeding Scan (with active bleeding), Colonscopy (with slow or stopped bleeding, try to prep colon), may need Angiography if above modalities ineffective. Consider OR intervention when bleeding site defined or with life threatening bleed