Case 3

What is the patient was a 70-year-old woman who presents with a chief complaint of  having a large, bloody bowel movement? Earlier in the day, the patient experienced  the urge to defecate and then passed a large quantity of blood. She had no nausea, vomiting, abdominal pain, tarry stool or lightheadedness. Although she appeared pale in the ER, she was alert and talkative. Her pulse was 110/min and regular. Her blood  pressure, in a supine position was 150/70 mmHg, which fell to 130/60 when she sat up. The examination of the abdomen revealed normal active bowel sounds and no tenderness, masses or organomegaly.  Rectal exam revealed large external hemorrhoids but no masses.  Stool was grossly bloody.  The hematocrit was 27%, WBC was 10,500 cells/mm³ without a left shift.  Platelets were 347,000/mm³ .  Prothrombin time was 10.2 seconds.  BUN and creatinine were 12 mg/dL and 0.6 mg/dL respectively.  The initial workup was negative for a specific bleeding site.  During hospitalization the stool was negative for blood; however, she passed a bloody stool on the fourth hospital day.