Managing Blood in Stool: A Case Study of a 70-Year-Old Dialysis Patient

Maternal hematochezia issue?

Dear Dr.
Hsu,
My mother, who is 70 years old, began dialysis in January 2015 due to 20 years of diabetes and hypertension.
In mid-2015, she experienced rectal bleeding that led to anemia.
The dialysis center performed multiple blood transfusions and requested examinations.
She underwent two gastroscopies at different hospitals, but no source of bleeding was found.
Prior to the anesthesia assessment for a painless colonoscopy, she underwent cardiac stent placement in December 2015.
After reducing her anticoagulant medication, the colonoscopy was performed, and the physician reported that the intestines appeared normal.
It was suggested to conduct an abdominal CT scan if there was further rectal bleeding.
In March 2016, a CT scan was performed, but again no source of bleeding was identified.
Another gastroscopy was conducted, and no bleeding source was found.
Due to concerns about the risks associated with enteroscopy and considering that the abdominal CT scan did not reveal any bleeding, my mother preferred to return home for recovery.
After taking hemostatic agents (aspirin has been discontinued), she has not experienced any further rectal bleeding.
Aside from performing an enteroscopy, what other options do we have to address this situation? Thank you for your assistance amidst your busy schedule!

Su Huan-yu, 50~59 year old female. Ask Date: 2016/04/13

Dr. Xu Kaixi reply Surgery

Gastrointestinal bleeding includes upper gastrointestinal bleeding and lower gastrointestinal bleeding.
The former can be ruled out through gastroscopy, while the latter can be excluded through colonoscopy to identify colonic sources of bleeding.
For small bowel bleeding, computed tomography can be considered for the initial exclusion of small bowel tumor bleeding.
However, diagnosing other visually subtle small bowel bleeding is more challenging.
In addition to enteroscopy, angiography, capsule endoscopy, and RBC scans can also be considered for further evaluation.

Reply Date: 2016/04/13

More Info

Managing blood in stool, especially in a complex case like that of a 70-year-old dialysis patient with a history of diabetes and hypertension, requires a comprehensive approach. Your mother’s situation is particularly challenging due to her multiple health issues and the extensive investigations that have already been performed without identifying a clear source of bleeding.

Firstly, it’s important to understand that the presence of blood in the stool can arise from various sources within the gastrointestinal tract, including the upper GI tract (esophagus, stomach, duodenum) and lower GI tract (small intestine, colon, rectum). Given your mother’s history of anemia and the fact that she has undergone multiple endoscopic evaluations (both upper and lower), it is crucial to consider less common causes of gastrointestinal bleeding.

Potential Causes of Blood in Stool:
1. Angiodysplasia: This is a vascular malformation that can lead to intermittent bleeding, often seen in older adults. It may not always be detected during standard endoscopic evaluations.

2. Small Bowel Pathologies: Conditions such as Crohn’s disease, small bowel tumors, or even ischemic enteropathy (especially relevant in patients with vascular disease) can cause bleeding that is not easily visualized through standard colonoscopy or upper endoscopy.

3. Hemorrhoids or Anal Fissures: While these are common causes of bright red blood in the stool, they typically present with pain and are often visible upon examination. However, they can coexist with other conditions.

4. Medications: While you mentioned that aspirin has been discontinued, other medications, including anticoagulants or non-steroidal anti-inflammatory drugs (NSAIDs), can contribute to gastrointestinal bleeding.

Recommendations for Management:
1. Monitoring: Since your mother has not experienced further episodes of blood in her stool after stopping aspirin and taking hemostatic agents, careful monitoring is essential. Keep a detailed record of any further episodes, including the volume and appearance of the blood, associated symptoms (like pain or changes in bowel habits), and any potential triggers (such as dietary changes).

2. Dietary Adjustments: Encourage a diet rich in fiber to prevent constipation, which can exacerbate hemorrhoids or fissures. Adequate hydration is also crucial, especially for a dialysis patient.

3. Follow-Up Imaging: If bleeding recurs, consider discussing the possibility of advanced imaging techniques such as a CT enterography or a capsule endoscopy, which can visualize the small intestine without the risks associated with traditional endoscopy.

4. Consultation with Specialists: Engaging a gastroenterologist who specializes in complex cases may provide additional insights. They may recommend further evaluations or alternative diagnostic approaches based on her unique medical history.

5. Regular Check-Ups: Given her age and health status, regular follow-ups with her healthcare team are vital. This ensures that any new symptoms are addressed promptly and that her overall health is monitored closely.

6. Consideration of Other Conditions: Given her history of diabetes and hypertension, it may be worthwhile to evaluate her for conditions like diabetic enteropathy or vascular complications that could contribute to gastrointestinal issues.

In summary, while the absence of findings from previous investigations can be frustrating, it is essential to remain vigilant and proactive in managing your mother’s health. Continuous monitoring, dietary management, and open communication with her healthcare providers will be key to addressing any future concerns regarding blood in her stool.

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