Lower GI Bleeding on Coumadin

74 yo AAF was admitted to the hospital with CC: Rectal bleeding x 1 day. Bleeding started gradually, getting worse, BRBPR, mixed with stool, no rectal or abdominal pain, 4 BM since yesterday, no similar symptoms before. She felt weak for 2 days.

PMH:
Admitted for CP and hematemesis 5 months ago. EGD showed an actively bleeding Mallory-Weiss tear, she was on NSAIDs at that time. Cath. showed stenosis Cx 60%, LAD 40%, EF 45%; medical management recommended.
She had a CVA with left sided weakness 1 year ago, the weakness resolved and she has been Coumadin for stroke prophylaxis ever since.

HTN, COPD, CVA, CAD, Mallory-Weiss tear, hyperchol.

Medications:
ASA, Coumadin, Lisinopril, Imdur, Lipitor, Protonix

SH:
no EtOH, 30 pck-yrs of smoking, no drugs

Physical examination:
VS: 37-16-43-110/76 with orthostatic changes
WD/WN in NAD
Neck: no JVD
Chest: CTA (B)
CVS: Clear S1S2, bradycardic at 44-55 bpm, irregular rhythm
Abd: Soft, NT, ND, +BS
Rectal: BRBPR
Ext: no edema
Neuro: AAO x 3, non focal


Labs

WBC 4, Hgb 11.5, Plt 169
INR 2.17
BUN 14 / Cr 0.9
LFT WNL


EKG - click to enlarge


Questions and Answers

What to do?

Transfer to ICU, NS 250 cc bolus and then 150 cc/hr, check INR/PTT, type and screen 2U PRBC, CBCD. CMP stat

Why is she orthostatic?
Blood loss – can be lower GI (most likely) but can be brisk upper GI bleed. also. BUN/Cr WNL is against upper GI bleeding.
Consult GI stat – she needs a colonoscopy.

Why is she bradycardic?
Sinus brady- with PVCs. Need to r/o ischemia with CPP x 2 and serial EKGs. May be due to SSS. Consult cardiology.

DDx of lower GI bleeding?
H-DRAIN:
Hemorrhoids (most common)
Diverticulosis - it is most likely in this patient
Radiation colitis
Angiodysplasia
IBD, Infection, Ischemic colitis
Neoplasia
For this patient the most likely cause is diverticulosis (no pain) and the bleeding can’t stop b/o Coumadin. What is the INR?

What happened?
TF to ICU
Coumadin and ASA held
INR was 2.17 but this is a serious bleed.-> Vit.K 5 mg SQ x 1 was given, 2U FFP
H&H q 4hr

Colonoscopy showed diverticulosis, polyps, massive bleeding which had stopped


Cardiology reviewed the EKG: Sinus brady- with PVCs, may be SSS

F/U:
Patient was stable, bleeding stopped, Coumadin was discontinued and she was TF back to RMF. She did not need blood transfusions.

Probably she did not need Coumadin in the first place for CVA prophylaxis as long as she is on ASA.

Final diagnosis:
Lower GI bleeding due to diverticulosis

What did we learn from this case?
Transfer unstable patients to the unit early.
Common things happen commonly - bleeding was due to diverticulosis.
Correct INR even if it is just 2 when the patient is having a major bleeding.

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