A 68-Year-Old Man With Hematochezia: What Is the Best Approach to Management?

Author:
Ronald N. Rubin, MD—Series Editor

Citation:
Rubin RN. A 68-year-old man with hematochezia: what is the best approach to management? Consultant. 2018;58(5):e171.

A 68-year-old man was awakened the previous night with a strong urge to move his bowels, which was an uncommon situation for him. When he did so, he had a diarrheal, loose bowel movement with maroon and bright red blood. This was repeated 2 more times during the night, prompting him to present to urgent care for evaluation.

At presentation, he was afebrile, with a reclining pulse rate of 92 beats/min and a blood pressure of 108/68 mm Hg. Postural testing was not performed. He had no abdominal tenderness and had good bowel sounds. Liquid maroon stool was present in the rectum. No hemorrhoids were seen.

His history was positive for type 2 diabetes, controlled with oral agents. He also had sustained an anterior acute myocardial infarction 11 months ago and had undergone stenting of his right coronary artery. He has been on daily metoprolol and 81 mg aspirin since then.

Electrocardiography (ECG) revealed a remote anterior infarction with no new acute injury currents, findings that were essentially unchanged from his last ECG. Troponin levels were normal. He had a random blood glucose level of 138 mg/dL, a blood urea nitrogen (BUN) level of 33 mg/dL, and a creatinine level of 1.9 mg/dL—again, findings similar to his most recent test results 3 months ago. His hemoglobin (Hb) level was 11.9 g/dL with a mean corpuscular volume (MCV) of 90 µm3, compared with 14.9 g/dL with an MCV of 91 µm3 3 months ago.

He received 2 L of crystalloid fluids, and after 4 hours, his pulse rate was 84 beats/min and his blood pressure was 116/78 mm Hg. He had no further bowel movements. Repeated blood studies revealed normal troponin levels, a creatinine level of 1.8 mg/dL, a BUN level of 30 mg/dL, and an Hb level of 9.9 g/dL.