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Rectal exam reduces admissions, endoscopies, medical therapy in patients with GI bleeding

Stephen Padilla
06 Jul 2017

Rectal examination can reduce hospital admissions, endoscopies and medical therapy in patients with acute gastrointestinal (GI) bleeding, according to a recent study. It can also assist clinicians in making clinical management decisions.

“Our findings suggest that the rectal examination can be a useful tool in the initial triage of patients with acute GI bleeding,” researchers said. “Physician and healthcare system-related factors could be targeted to increase the use of this simple, inexpensive and useful bedside tool.”

Furthermore, rectal examination in patients with acute GI bleeding may be predicted by age, ethnicity, anticoagulant use, clinical features on presentation and time of presentation. However, researchers claimed that rectal examination is not performed in majority of these patients even though digital rectal examination is an established part of physical examination. [Am J Med 2017;130:819–825]

In this study, 549 (44 percent) out of 1,237 patients with acute GI bleeding did not have a rectal examination. Patients who underwent rectal examination were less likely to be admitted compared with those who did not (adjusted odds ratio [AOR], 0.49; 95 percent CI, 0.30 to 0.79; p=0.004).

In addition, patients who had a rectal examination were less likely to begin medical treatment (AOR, 0.64; 0.41 to 0.98; p=0.04) and to undergo endoscopy (AOR, 0.64; 0.44 to 0.94; p=0.02).

“Clinical management decision in patients with acute GI bleeding is often based on the nature and acuity of the bleed,” researchers said. “Lower GI bleeding is usually less dramatic than upper GI bleeding and is self-limiting in most cases.” [Nat Rev Gastroenterol Hepatol 2009;6:637–646]

Early, aggressive management must be accorded to patients with high acuity, while those with low acuity may be considered for early hospital discharge or outpatient management. Apart from clinical condition and acuity, other reasons for hospital admission are diagnostic uncertainty and lack of information. [J Gen Intern Med 2016;31:37–44]

As an established part of physical examination in patients with GI bleeding, rectal examination can provide useful information quickly, easily and safely.

“Finding of gross blood, stool mixed with blood or melena on rectal examination can provide objective evidence of bleeding to a clinician and may help differentiate upper GI from lower GI source of bleeding,” researchers said. [Dig Dis Sci 1995;40:1614–1621]

“Furthermore, finding of red blood or melena on rectal examination is predictive of increased risk of rebleeding and mortality in patients with nonvariceal upper GI bleeding,” they added. [Ann Intern Med 2003;139:843–857]

In this single-centre, retrospective, cross-sectional study, researchers used data from electronic health records of patients aged ≥18 years presenting to the emergency department with acute GI bleeding. The main outcomes were hospital admissions, intensive care unit admissions, gastroenterology consultation, initiation of medical therapy (proton pump inhibitor or octreotide) and inpatient endoscopy.

“Further studies are needed to investigate whether proper physical examinations would affect resource use and hospital admission rates in these patients,” researchers said.

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