Questions for Discussion:

  1. What would be your initial management of this patient? What clues from the history, physical examination, and laboratory evaluation suggest the site of the GI bleeding?

The patient is admitted to your service and a further history of osteoarthritis and gastric ulcer is elicited although documentation of the ulcers is poor. She takes NSAID's when her arthritis flares. There is no weight loss and she denies anorexia. No history of alcohol ingestion. A brother died of colon cancer.

  1. What is a reasonable differential diagnosis?
  2. Outline a strategy to evaluate this patient?

The next morning after three units of packed red cells, the hemoglobin and hematocrit are not significantly changed from admission. The nurse reports one large maroon bowel movement overnight. The vital signs are stable and three is no orthostasis. The patient underwent upper and lower endoscopy in the GI lab. The colonoscopy revealed normal mucosa, no blood in the colon, and there was multiple sigmoid diverticulosis, no bleeding. The upper GI endoscopy (EGD) was normal. There was no further bleeding over the next two days and she was able to eat. On the fourth hospital day, she experienced another episode of hematochezia. She did not require additional transfusions and the vital signs remained stable.

  1. What is the most likely diagnosis that can account for the GI bleeds?
  2. What further diagnostic modalities can be employed at this point and what are the advantages and disadvantages of each?
  3. How would you manage the patient at this point in time?

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