A 79 year-old man presented with one day of spontaneous hematochezia. He denied abdominal pain, abdominal distention, or weight loss. His past medical history included chronic kidney disease. Notable findings on his admission exam were tachycardia, a soft, non-tender abdomen, and approximately 5 ml of dark red blood in the rectal vault. His hemoglobin upon admission was 7.1 g/dl. BUN and creatinine levels were 60 mg/dl and 2.3 mg/dl; the platelet count was 132,000 per microliter; the prothrombin time was normal. He was not taking any platelet inactivating drugs or anticoagulants. The patient was admitted to the ICU for monitoring and treatment. Two units of packed red cells were transfused due to a subsequent hemoglobin of 5.7 g/dl. Colonoscopy revealed moderately severe diverticulosis with no evidence of active bleeding; visualization of mucosa was poor due to incomplete preparation. A third unit of packed red cells was given due to a hemoglobin value of 6.6 g/dl. The patient was hemodynamically stable and transferred to the floor. On the fourth hospital day, digital rectal exam revealed frank blood, and the patient was transferred back to the ICU. Subsequent technetium-99m red cell scan disclosed no significant bleeding. An additional unit of packed red cells was given for a hemoglobin of 6.4 g/dl, and surgical consultation was obtained. While hospitalized, significant gastrointestinal hemorrhage occurred, necessitating immediate return to the ICU. Severe abdominal pain, agonal breathing, hypovolemic shock, and cardiac arrest ensued within minutes. Despite immediate large-volume resuscitation efforts, the patient expired.
Hospitalists frequently encounter lower gastrointestinal bleeding. Hemorrhage from colonic diverticula is the most common cause of hematochezia in patients >60 years, and about 20% of patients with diverticulosis have gastrointestinal bleeding. Factors associated with an increased risk of bleeding include hypertension, atherosclerosis, and non-steroidal anti-inflammatory drug use. Diverticular bleeding spontaneously ceases in 70-80% of patients. About 25% of patients experience re-bleeding. The chance of a third bleed after a second episode is as high as 50%, leading some to recommend surgical resection after a second bleeding episode.
Appropriate management of hematochezia of any cause is determined by the clinical stability of the patient. Hemodynamically unstable patients should proceed directly to surgery. In stable patients, the etiology of the bleed should be determined using endoscopy, arteriography, and tagged red cell scanning, as appropriate. Patients receiving 6 or more units of red cells in 24 hours are considered unstable. It should be noted that endoscopic visualization of a potentialbleeding site (e.g., non-bleeding hemorrhoids or diverticula) does not exclude the presence of more proximal pathology. Refractory diverticular bleeding should be defined as any second bleeding episode following hemostatic resolution of the initial bleed. The hospitalist should be fully aware that patients with refractory diverticular bleeding are highly prone to subsequent bleeding episodes, rapid clinical decompensation, and death.
While management of initial diverticular bleeds tends to be supportive care, hospitalists should remain cautious with recurrent diverticular bleeds. These bleeds can be life-threatening and may require critical care and surgical management.
To cite this abstract:Harris ZM, Lasky J. Refractory Diverticular Hemorrhage in an Initially Stable ICU Admission. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 546. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/refractory-diverticular-hemorrhage-in-an-initially-stable-icu-admission/. Accessed July 19, 2019.