A 75-year-old woman passed out in church. She is presently pale and clammy. Her physical examination is otherwise unremarkable except for burgundy-colored stool in her rectal vault. Her heart rate is 80/min, and her blood pressure is 100/50 mm Hg. Her hemoglobin is 4.7 mg/dL. Your most appropriate approach should be to:
Resuscitate with crystalloid and blood, order contrast-enhanced CT scan of the abdomen, and consult general surgeon.
+Resuscitate with crystalloid and blood; insert a nasogastric tube. If positive, consult endoscopist, if negative, arrange for angiography or technetium-tagged red blood cell scan.
+Resuscitate with crystalloid only, consult diagnostic and therapeutic endoscopist for esophagogastroduodenoscopy (EGD).
+Resuscitate with crystalloid and blood, consult general surgeon for laparotomy.
+Resuscitate with crystalloid only, obtain surgical consultation.
Blood per rectum can signal either upper or lower GI bleeding. Placement of a nasogastric tube with lavage can rule out bleeding proximal to the pylorus. If blood is found, then EGD is the diagnostic and therapeutic maneuver of choice. If no blood is found (but bile is aspirated), then a lower GI source of bleeding is more likely. Angiography sometimes can detect the site of bleeding, but requires a relatively brisk bleeding rate (0.5–2.0 mL/min) to be diagnostic. Technetium-labeled red cell scintigraphy is even more sensitive than angiography and can localize the site of bleeding at a rate of 0.1 mL/min. The hemoglobin is critically low, and blood transfusion should be started along with crystalloid infusion. CT scan has only a minimal role in the management of GI bleeding. Laparotomy is not indicated until the bleeding is localized by other tests to the upper or lower GI system.