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vaginal metronidazole; answer D, oral clindamycin; and answer E, oral estrogen
and progestin) do have not a predisposition to follow antibiotic use.
22.3 A. An option for outpatient therapy of PID is intramuscular ceftriaxone and
oral doxycycline. Oral metronidazole as a single dose (answer C) is a treatment for Trichomonas vaginitis. Fluoroquinolones (answer D, ciprofloxacin)
are not recommended in the United States for the treatment of gonorrhea or
associated conditions, such as PID, due to increasing rates of resistance.
CLINICAL PEARLS
» Remember to treat sexual partners when you diagnose an STI and to test
for other STIs that may initially be asymptomatic, such as HIV, hepatitis B
and C, and syphilis.
» Single-dose therapy is available for many types of infections, including
Trichomonas, gonococcal and chlamydial cervicitis, and Candida vaginitis.
Providing single-dose therapy in your office will improve your patient’s
compliance as well as rates of successful treatment.
» Most women have at least one episode of Candida vulvovaginitis during
their lifetime. Symptoms include a thick, whitish discharge that has no
odor and significant pruritus of the external and internal genitalia.
» The presenting complaint in trichomoniasis is copious amounts of a thin,
frothy, green-yellow or gray malodorous vaginal discharge.
» Bacterial vaginosis arises when normal vaginal bacteria are replaced with
an overgrowth of anaerobic bacteria and G. vaginalis. Although not sexu-
ally transmitted, it is associated with having multiple sexual partners.
Treatment of BV in pregnant women may reduce the incidence of miscarriage and postpartum endometritis.
» The presence of lower abdominal tenderness with both adnexal and cer-
vical motion tenderness, without other explanation of illness, is enough
to diagnose PID.
REFERENCES
Gradison M. Pelvic inflammatory disease. Am Fam Physician. 2012;85(8):791-796.
Maier R, Katsufrakis PJ. Sexually transmitted diseases. In: South-Paul JE, Matheny SC, Lewis EL, eds.
CURRENT Diagnosis & Treatment: Family Medicine. 4th ed. New York, NY: McGraw Hill; 2015:
Chap. 14. http://accessmedicine.mhmedical.com/content.aspx?bookid=1415&Sectionid=77055487.
Accessed March 2019.
Paladine HL, Desai UA Vaginitis: diagnosis and treatment. Am Fam Physician. 2018;97(5):321-329.
Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases
treatment guidelines, 2015. MMWR Recomm Rep. 20155;64(RR-03):1-137.
CASE 23
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A 62-year-old man presents to your office for a routine evaluation. His only
complaint is of fatigue over the past 2 to 3 months despite no changes in diet
or lifestyle. On questioning, the patient reports that he has never smoked and
admits to an increase in his consumption of alcohol upon retiring, to about two to
three beers per day. He has occasional headaches the day after a night of heavier
drinking and takes ibuprofen for the headaches. As you talk to the patient and
examine his chart, you note no distress and proceed with your examination.
Compared to a visit from 6 months ago, you note a 4-lb weight loss and an increase
in his pulse. His blood pressure is 129/81 mm Hg. He has pale conjunctivae, but
the rest of his general examination is unchanged from the previous examination.
You perform a digital rectal examination and find a smooth, normal-size prostate;
some soft, reducible protrusions within the internal sphincter; and guaiac-positive
stool. You decide on a more direct approach and delve into his drinking, bowel
habits, and medication use. His only addition is the occasional production of
bloody stools accompanied by some diffuse abdominal discomfort.
▶ What is the most likely diagnosis?
▶ What is your next diagnostic step?
▶ What is the next step in therapy?
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ANSWERS TO CASE 23:
Lower Gastrointestinal Bleeding
Summary: A 62-year-old man presents with
Desire for a routine checkup
Fatigue for 2 to 3 months
Increased alcohol intake
Occasional bloody stools, as well as headaches, for which he takes ibuprofen
Guaiac-positive stool
Stable vital signs and pale appearance
Most likely diagnosis: Hemorrhoids.
Next diagnostic step: Complete blood count (CBC) and colonoscopy.
Next step in therapy: Avoid nonsteroidal anti-inflammatory drug (NSAID) use and
decrease alcohol consumption.
ANALYSIS
Objectives
1. Know how to recognize the subtle signs and symptoms of lower gastrointestinal (GI) bleeding. (EPA 1)
2. Understand the etiologies of lower GI bleeding. (EPA 2)
3. Understand how to correctly evaluate and treat patients with lower GI bleeding in outpatient settings. (EPA 3, 4)
Considerations
This 62-year-old man presented to your office for a routine examination but is
found to have some type of lower GI bleeding that needs further evaluation. During his office visit, there are no signs of hemodynamic instability or active bleeding
that require immediate referral to an emergency department or inpatient treatment, so close outpatient follow-up is reasonable. His immediate identifiable and
modifiable risk factors for GI bleeding include the regular consumption of alcohol
and NSAIDs. This patient should be counseled on both these matters and sent
to the laboratory for a CBC, chemistry panel, liver function tests, and coagulation
profile prior to his discharge home from your office. Barring any abnormal laboratory values that require emergent management, he should be scheduled for an
outpatient colonoscopy later in the week. The differential diagnosis at this time is
wide, but the most frequent offenders in his age group should be considered. These
include diverticular disease, hemorrhoids, colon and rectal tumors, and ulcerative
colitis. For the time being, factors that may contribute to any of these etiologies
should be modified while awaiting laboratory results.
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APPROACH TO:
Lower Gastrointestinal Bleeding
DEFINITIONS
HEMATOCHEZIA: Bright red blood visible in the stool.
LOWER GASTROINTESTINAL BLEEDING: Bleeding that comes from a
source distal to the ligament of Treitz.
MELENA: Dark, sticky feces containing partly digested blood.
CLINICAL APPROACH
Pathophysiology
The most common causes of lower GI bleeding include hemorrhoids (59%), colorectal polyps (38% to 52%), diverticulosis (34% to 51%), colorectal cancer (8%), ulcerative colitis, arteriovenous malformations, and colonic strictures. Percentages vary
among age groups, and most serious causes are expected in the elderly.
Hemorrhoids. Hemorrhoids are dilated veins in the hemorrhoidal plexus of the
anus. They are defined as “internal” if they arise above the dentate line and “external”
if they arise below the dentate line. Both can be the cause of hematochezia. Chronic
constipation, straining for bowel movements, pregnancy, and prolonged sitting
(eg, truck drivers) are risk factors. Along with bleeding, external hemorrhoids can
cause pain, irritation, and a palpable lump. Internal hemorrhoids can cause bleeding and can prolapse through the anus. Conservative treatment with a high-fiber
diet, stool softeners, sitz baths, and precautions against prolonged straining are
usually successful. When necessary, surgical procedures can be performed for definitive treatment.
Diverticular Disease. Diverticula are outpouchings of the colonic mucosa
through weakened areas of the colon wall. They occur most often where blood vessels penetrate through the muscles of the colon. They are most often asymptomatic
and found on endoscopy or bowel imaging studies. They can cause symptomatic, and
occasionally massive, bleeding that is usually painless. Diverticular bleeding occurs
in 10% to 20% of cases of lower GI bleeding. In diverticular disease, bleeding is
often self-limited and ceases approximately 75% of the time; it recurs at a rate of
approximately 38%. When the bleeding is extremely heavy or fails to stop, surgical resection of the affected portion of the colon may be necessary. Asymptomatic
diverticulosis is managed with dietary modification, primarily a high fiber diet.
Diverticulitis is a painful inflammation and infection of a diverticulum. Diverticulitis frequently causes left lower quadrant abdominal pain along with fever, nausea,
diarrhea, and constipation. Perforation of a diverticulum resulting in peritonitis or
intra-abdominal abscess formation can be a complication. Diverticulitis is typically
treated with bowel rest and antibiotics effective against gut flora. A combination
of a quinolone and an agent for anaerobic organisms, such as metronidazole, is
one commonly used regimen. In severe cases, recurrent cases, or when perforation
occurs, surgery is indicated.
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Inflammatory Bowel Disease. Ulcerative colitis and Crohn disease are the two
primary diagnoses considered in the category of inflammatory bowel disease
(IBD). Ulcerative colitis causes continuous inflammation of the large bowel, start-
ing from the rectum and extending proximally. Severe disease can cause pancolitis, affecting the entire colon. Crohn disease causes areas of focal inflammation, but
it can occur anywhere in the GI tract, with healthy colon occurring in between (skip
lesions). Both diseases can cause recurrent episodes of abdominal pain, diarrhea,
weight loss, rectal bleeding, fistulas, and abscesses. The definitive etiology of IBD
is not known, but these are autoimmune syndromes, and a family history of IBD
is a major risk factor. Along with GI symptoms, numerous extraintestinal manifes-
tations may occur, most frequently arthritis. Other extraintestinal manifestations
include sclerosing cholangitis, cirrhosis, fatty liver, pyoderma gangrenosum, and
erythema nodosum. Ulcerative colitis is a significant risk factor for the development of colon cancer. Patients with ulcerative colitis require frequent surveillance
colonoscopies. IBD can be managed with symptomatic therapy, such as antidiarrheal medications, along with anti-inflammatory medications (aminosalicylates,
corticosteroids) given orally or as enemas, and immunosuppressive medications.
Ulcerative colitis can be definitively treated with a total colectomy, which is usually reserved for severe pancolitis, failure to respond to medical therapy, or cases
for which the risk of colon cancer is significant (eg, disease present for 10 years).
The rate of colectomy has steadily decreased recently due to newer immunomodulator therapy.
Colon Neoplasms. Polyps are benign neoplasms of the colon. Hyperplastic
polyps tend to be small, smooth growths found incidentally during endoscopy and
are of no prognostic significance. Adenomatous polyps are benign growths that
have a potential to become malignant. Listed in order of potential for becoming
cancerous (from least to most), the three types of adenomas are tubular adenomas,
tubulovillous adenomas, and villous adenomas. Larger polyps have a higher risk of
causing bleeding and becoming malignant than smaller polyps. Polyps can be identified and removed during endoscopic procedures.
Colon cancer is the third most common cancer and the second leading cause
of cancer deaths in men and women. The risk of colon cancer increases with age,
a history of colon polyps, a family history of colon cancer, or a personal history of
ulcerative colitis. Any patient older than age 50 years who has lower GI bleeding or
unexplained anemia must be evaluated for the presence of colon cancer. Because of
the presence of premalignant lesions (polyps) that can be identified and removed
in asymptomatic patients, colon cancer screening is recommended for all adults
older than age 50 and at younger ages for those with increased risks. The treatment and prognosis of colon cancer depends upon the stage in which it is found.
The preferred staging system for colon cancer is the TNM classification. The T
in TNM refers to the primary tumor, which is staged based on the penetration of
the tumor through the bowel wall layer. The N refers to the number of regional
lymph nodes that are positive, and the M refers to distant metastasis. Both the
stage and the grade of colorectal tumors contribute to prognosis, with the worst
prognosis predicted for patients with distant metastasis and histologically highgrade tumors.
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Clinical Presentation
The manifestations of GI bleeding depend on the source, rate of bleeding, and underlying or coexisting disease. An older patient or someone with significant comor-
bidities, such as coronary artery disease, would be at a higher risk of presenting in
shock. A younger, healthier individual may present with symptoms such as fatigue
or dyspnea on exertion or may complain directly of seeing blood in the stool. Signs
and symptoms of anemia are common and include weakness, easy fatigability, pallor of the conjunctivae or skin, chest pain, dizziness, tachycardia, hypotension, and
orthostasis.
A history of blood in the stool or finding guaiac-positive stool on examination should prompt further evaluation to determine the source of the bleeding.
Depending on a patient’s history and hemodynamic status, more immediate and
invasive measures may be necessary once GI bleeding is identified. For example,
hematochezia is usually pathognomonic of lower GI bleeding but can also be found
in patients with heavy upper GI bleeding. In this setting, a nasogastric aspirate may
help differentiate this small subset of patients. An aspirate that shows bile but not
blood will help to confirm that the bleeding is from a lower GI source. Melena is
usually associated with upper GI bleeding, but it may also be associated with a slowrate lower GI bleed.
The test of choice for the determination of the source of a lower GI bleeding is
colonoscopy. Adequate bowel preparation with an oral sulfate purge to clear the
bowel of blood, clots, and stool increases the yield in diagnosing colonic bleeding
sites. Angiography and technetium-labeled colloid or red blood cell scans may be
of value if colonoscopy cannot be performed or if heavy bleeding prevents adequate
visualization of the colon. However, the magnitude of bleeding required to reveal
the bleeding site limits their usefulness. Sigmoidoscopy with air contrast barium
enema x-rays may be an alternative when colonoscopy is unavailable or if the patient
refuses colonoscopy. If the initial sigmoidoscopy is negative, a colonoscopy must be
performed. If both of these studies are negative, panendoscopy should be carried
out. Capsule endoscopy has a diagnostic yield of 61% to 74% and can be done when
a source of bleeding is still elusive after both upper and lower GI endoscopy.
Treatment
Treatment should be based upon the etiology of the GI bleeding. Additionally, modifiable risk factors for GI bleeding (eg, alcohol, NSAID use) should be
addressed. Hemodynamically stable patients can be treated as outpatients, pending
colonoscopy or other diagnostic measures.
It is critical to transport unstable patients who present with GI bleeding to the
emergency department for hospitalization. Instability is indicated by persistent
hypotension, tachycardia, and other signs or symptoms of shock. Intensive care
unit admission should not be delayed in those with severe bleeding, and a team
approach, consisting of a gastroenterologist, a surgeon with expertise in GI surgery,
and skilled nursing, should always be anticipated. Major causes of morbidity and
mortality in patients with GI bleeding include blood aspiration and shock. To prevent these complications, endotracheal intubation should always be considered to
protect the airway of patients with altered mental status. Most cases of lower GI
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bleeding do not warrant emergency therapy, but be prepared for decompensation in
the elderly and in those with borderline normal hemodynamic parameters.
CASE CORRELATION
See also Case 1 (Adult Male Health Maintenance), Case 9 (Anemia in
the Geriatric Patient), and Case 11 (Adult Female Health Maintenance).
COMPREHENSION QUESTIONS
23.1 A 52-year-old man presents with a 2-hour history of acute bright red blood
per rectum. In the emergency center, his pulse is 110 beats/min, blood pressure is 90/50 mm Hg, he is cool and clammy appearing, and he has gross
blood present on rectal examination. Which of the following is the best initial
next step?
A. Colonoscopy
B. Flexible sigmoidoscopy
C. Placement of a nasogastric tube
D. Bolus of intravenous normal saline
E. Transfusion of type O-negative blood
23.2 A 67-year-old man presents to the clinic for a routine checkup. He complains
of mild fatigue and occasional dyspnea on exertion. Physical examination is
notable for conjunctival pallor. A rectal examination notes no hemorrhoids or
masses but guaiac-positive stools. A CBC reveals a hemoglobin of 10 g/dL
and a hematocrit of 27%; iron studies are consistent with iron deficiency.
What is the most appropriate next step in evaluation and management?
A. Tagged red blood cell scan
B. Iron supplementation
C. Colonoscopy
D. Anoscopy
E. Repeat stool hemoccult in 2 weeks
23.3 A 25-year-old man has a colonoscopy for diagnostic evaluation of abdominal
pain, weight loss, diarrhea, and blood in the stool. The colonoscopy shows
diffuse mucosal inflammation in the anus and descending colon. Which of
the following is the most likely diagnosis?
A. Ulcerative colitis
B. Crohn disease
C. Pseudomembranous colitis
D. Colon cancer
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ANSWERS
23.1 D. The initial evaluation of this acutely ill patient is “ABC”—airway, breathing, and circulation. As he appears to be in hypovolemic shock, with tachycardia and hypotension, a bolus of an isotonic crystalloid fluid, such as normal
saline or lactated Ringer solution, is necessary before proceeding with any
of the other evaluations. Further evaluation for this patient should include
a CBC, blood transfusion as necessary (answer E), and other evaluation to
determine the source of bleeding, such as colonoscopy (answer A), flexible
sigmoidoscopy (answer B), or nuclear medicine bleeding scan. Answer C
(nasogastric tube) is not indicated since this is a lower GI process and not an
upper GI process.
23.2 C. Colonoscopy is the most appropriate next step and is an essential evaluation in any older adult with unexplained iron-deficiency anemia. Irondeficiency anemia can be a common presenting symptom of colon cancer.
Tagged red blood cell scans (answer A) have limited indications only in
acute, large-volume GI bleeding where colonoscopy is unable to be performed.
Anoscopy (answer D) would give some examination of the rectum but does
evaluate the colon appropriately. Iron supplementation without evaluating the
cause of the iron deficiency (answerB) is inappropriate. A repeat stool occult
blood (answer E) is not necessary to confirm the results of a guaiac-positive
stool.
23.3 A. Ulcerative colitis causes continuous inflammation of the colon anywhere
from rectum only to the entire colon, whereas Crohn disease (answer B)
causes patchy inflammation with skip areas throughout the alimentary canal
but often the ileum and right side of colon. Pseudomembranous colitis
(answer C) is a complication of Clostridium difficile infection of the colon.
Answer D (colon cancer) would not present as diffuse mucosal inflammation
and instead would be a tumor or growth.
CLINICAL PEARLS
» Lower GI bleeding is usually suspected in lesions or pathology that is dis-
tal to the ligament of Treitz. Simple measures like nasogastric lavage can
aid in ruling out upper GI bleeding as a cause of hematochezia.
» In a patient with acute lower GI bleeding, consider performing colonos-
copy. Other diagnostic procedures that may be useful include radionuclide imaging and mesenteric angiography.
» Any patient older than age 50 years should be screened for colon cancer.
If a patient has a family history of colon cancer, colonoscopy screening
should be performed 10 years prior to the age of diagnosis in the relative,
or at age 50, whichever comes first.
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REFERENCES
Ahmed R, Gearhart SL. Diverticular disease and common anorectal disorders. In: Kasper D, Fauci A,
Hauser S, Longo D, Jameson J, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 20th ed.
New York, NY: McGraw Hill; 2019: Chap. 353. http://accessmedicine.mhmedical.com/content.
aspx?bookid=1130&Sectionid=79748127. Accessed January 25, 2019.
Bull-Henry K, Al-Kawas FH. Evaluation of occult gastrointestinal bleeding. Am Fam Physician.
2013;87(6):430-436.
Fargo MV, Latimer KM. Evaluation and management of common anorectal conditions. Am Fam
Physician. 2012;85(6):624-630.
Gralnek IM, Neeman Z, Strate LL. Acute lower gastrointestinal bleeding. N Engl J Med. 2017;
376:1054-1063.
CASE 24
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A 61-year-old woman presents to the emergency department complaining of a
cough for 2 weeks. The cough is productive with green sputum and is associated
with sweating, shaking chills, and fever up to 102°F (38.8°C). She was exposed
to her grandchildren, who were told that they had upper respiratory infections
2weeks ago but now are fine. Her past medical history is significant for diabetes
for 10 years, which is under good control using oral hypoglycemics. She denies
tobacco, alcohol, or drug use. On examination, she looks ill and in distress, with
continuous coughing and chills. Currently, her blood pressure is 100/80 mm Hg,
pulse is 110 beats/min, temperature is 101°F (38.3°C), respirations are 24 breaths/
min, and oxygen saturation is 97% on room air. Examination of the head and
neck is unremarkable. Her lungs have rhonchi and decreased breath sounds,
with dullness to percussion in bilateral bases. Her heart is tachycardic but regular.
Her extremities are without signs of cyanosis or edema. The remainder of her
examination is normal. A complete blood count (CBC) shows a high white blood
cell count of 17,000 cells/mm3, with a differential of 85% neutrophils and 20%
lymphocytes. Her blood sugar is 120 mg/dL.
▶ What is the most likely diagnosis?
▶ What is your next diagnostic step?
▶ What is the next step in therapy?
▶ What are potential complications to this condition?
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