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Approach to Gross Hematuria in a 70-Year-Old Male

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Step 1 - Confirm True Hematuria

• Obtain a clean midstream urine sample
• Send for microscopic urinalysis (not just urine dipstick)
  • Dipstick: sensitivity 91-100% but specificity only 65% - can be falsely positive with myoglobinuria, hemoglobinuria, beet ingestion, rifampicin, phenazopyridine
  • Confirm RBCs on microscopy (>3 RBCs/HPF = confirmed hematuria)

• Dysmorphic/crenated RBCs + RBC casts = glomerular origin (nephrology referral)
• Normal/isomorphic RBCs = lower urinary tract / non-glomerular bleeding (urologic workup)

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Step 2 - Focused History

Note: Anticoagulation use does NOT eliminate the need for full workup - hematuria on anticoagulation still requires complete urologic evaluation.

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Step 3 - Physical Examination

• BP - hypertension may suggest glomerular disease
• Abdominal exam - palpable renal mass (RCC), pulsatile mass (AAA - life-threatening, must not be missed)
• Abdominal bruit - arteriovenous fistula
• CVA (costovertebral angle) tenderness - pyelonephritis, calculi
• Digital Rectal Exam (DRE) - prostate size, nodularity (10% of recurrent gross hematuria has prostate cancer)
• Genital exam - meatal/urethral lesion, perineal trauma

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Step 4 - Initial Investigations

Urine

Blood

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Step 5 - Imaging (Upper Tract)

CT Urography (CTU) - Investigation of Choice

• Multi-phase CT: non-contrast + nephrographic + excretory (delayed) phase
• Best overall imaging for gross hematuria - detects:
  • Urothelial tumors of renal pelvis and ureter
  • Renal cell carcinoma
  • Urolithiasis
  • Hydronephrosis
  • Renal cysts, trauma
• Detects ~90% of upper tract malignant lesions
• Standard of care per AUA guidelines for gross hematuria

If contrast contraindicated (allergy, poor renal function): MR Urography is an acceptable alternative

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Step 6 - Cystoscopy (Mandatory)

• All patients with gross hematuria require cystoscopy - no imaging modality can adequately evaluate the bladder mucosa
• CT urography is not as sensitive as cystoscopy for bladder urothelial tumors
• Flexible cystoscopy preferred as an office procedure
• Allows direct visualization of:
  • Bladder tumors (papillary, sessile, CIS)
  • Bladder neck, trigone
  • Ureteral orifices (looking for lateralizing hematuria - blood jetting from one orifice = upper tract lesion)
  • Prostatic urethra
  • Urethra

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Step 7 - Special Considerations for This Patient (70M, No Comorbidities)

• Age >60 (strongest independent risk factor)
• Male sex
• Any episode of gross hematuria = automatic high-risk category regardless of other factors

• Any gross hematuria triggers complete urologic evaluation: CTU + cystoscopy + urine cytology
• Do NOT defer or watch - every episode must be investigated
• Even one negative urinalysis after gross hematuria does NOT eliminate need for workup

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Differential Diagnosis (Most to Least Likely in This Context)

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Diagnostic Algorithm Summary

Gross Hematuria (70Y Male)
         ↓
Rule out pseudohematuria (urine microscopy)
         ↓
Confirm UTI? → Treat → Re-check → If persists → Full workup
         ↓
History + Physical + DRE + PSA
         ↓
Labs: CBC, RFTs, coagulation, urine cytology, urine culture
         ↓
CT Urography (upper tract imaging)
         ↓
Cystoscopy (mandatory, regardless of CTU findings)
         ↓
         ├─ Mass/filling defect on CTU → Urologic oncology referral
         ├─ Bladder tumor on cystoscopy → TURBT + staging
         ├─ Lateralizing hematuria from ureteral orifice → Retrograde pyelogram + ureteroscopy
         └─ All negative → Consider nephrology referral (glomerular workup)

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Key Clinical Pearls

• Painless gross hematuria in a male >50 = bladder cancer until proven otherwise
• Even a single episode must be fully investigated - hematuria is often intermittent
• Anticoagulation is not an excuse to skip workup - it does not cause hematuria, it unmasks it
• Risk of malignancy on gross hematuria evaluation: ~20-40% vs 3-5% for microscopic hematuria
• 85% of newly diagnosed bladder cancers present with painless gross hematuria
• PSA should be considered - 10% of recurrent gross hematuria cases have prostate cancer
• If negative workup: low risk of malignancy for next 3-5 years, but any new gross hematuria triggers repeat full evaluation

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Approach to Coffee Ground Vomitus in a 52Y Male, 25 Days Post-Partial Gastrectomy

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Step 1 - Immediate Assessment: Is the Patient Stable or Unstable?

Signs of Hemodynamic Instability:

• HR >100 bpm (tachycardia)
• SBP <90 mmHg or postural drop >20 mmHg (orthostatic hypotension)
• Cold peripheries, poor capillary refill
• Altered consciousness, confusion
• Urine output <0.5 mL/kg/hr

Immediate Actions (ALL Patients):

• 2 large-bore IV cannulas (≥18G) or large-bore central cordis
• Oxygen - high flow via face mask
• Draw blood urgently: CBC, LFTs, RFTs, coagulation profile, blood group and crossmatch, serum electrolytes, ABG
• Urinary catheter - monitor urine output hourly
• ECG - rule out ischaemic event triggered by hemorrhage
• Nil by mouth
• If hematemesis ongoing + reduced consciousness = consider elective intubation (to protect airway before endoscopy)

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Step 2 - Resuscitation

Fluid and Transfusion Strategy:

ICU Admission Criteria:

• Active bleeding (hematemesis, bright red blood via NGT, or hematochezia)
• Hemodynamic instability not rapidly corrected by fluids
• Requires monitoring and close observation

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Step 3 - Risk Stratification Scoring

Glasgow-Blatchford Score (pre-endoscopy, helps triage):

• Score ≥1 = needs inpatient management and endoscopy
• Maximum 23; higher = greater risk of rebleeding/death

Rockall Score (complete = pre + post-endoscopy):

• Complete score ≤2 = low risk; score ≥8 = high risk of mortality
• Scores 5+ have ~40% rebleeding risk

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Step 4 - Differential Diagnosis in This Context (POD 25 Post-Partial Gastrectomy)

Special danger - Secondary Hemorrhage from vascular erosion: Bailey and Love specifically warns that "septic collections along with radical vascular dissection may lead to catastrophic secondary hemorrhage from exposed or divided blood vessels - very difficult to manage whether reoperation or interventional radiology is employed." This is the most feared complication.

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Step 5 - Pre-Endoscopy Optimization

Proton Pump Inhibitors (PPI):

• Start IV PPI immediately - do not wait for endoscopy
• Options:
  • IV PPI bolus every 12 hours (stable patients)
  • IV PPI continuous infusion (80 mg bolus then 8 mg/hr) - for high-risk / active bleeding; shown to significantly reduce rebleeding rate
• PPI neutralizes gastric acid → stabilizes blood clots → promotes hemostasis

Prokinetics (to improve endoscopic visualization):

• IV Erythromycin 250 mg over 20-30 min, given 20-90 minutes before endoscopy
• Mechanism: motilin receptor agonist → promotes gastric emptying → clears blood/clots from view
• Evidence: improves visualization (77% vs 51%), reduces need for repeat endoscopy (15% vs 26%)
• Monitor QTc - erythromycin can cause QT prolongation; check for drug interactions (CYP3A4 inhibitor)
• Alternative: Metoclopramide 10 mg IV

NGT Placement:

• Can be considered to aspirate gastric contents and confirm active bleeding, but NOT mandatory
• Bright red blood or "coffee grounds" in NGT confirms upper GI source

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Step 6 - Upper GI Endoscopy (OGD)

Timing:

Challenges in Post-Gastrectomy Anatomy:

• Altered anatomy (Billroth I, Billroth II, Roux-en-Y) affects scope navigation
• Expert endoscopist essential - standard scopes may not access all areas
• In Roux-en-Y: the gastric pouch, Roux limb, anastomosis, and excluded duodenum are all accessible
• Side-viewing duodenoscope or enteroscope may be needed to evaluate Billroth II afferent limb
• Risk of anastomotic disruption and perforation with air insufflation - use CO2 insufflation if available, minimize insufflation

Endoscopic Findings and Their Management:

Endoscopic Hemostatic Options:

1. Injection therapy - 1:10,000 adrenaline (epinephrine) - vasoconstriction + tamponade
2. Thermal coagulation - heater probe, argon plasma coagulation (APC)
3. Mechanical clips (hemostatic clips, over-the-scope clips - OTSC)
4. Hemostatic powders (TC-325/Hemospray) - useful for anastomotic ulcer bleeding, but temporary only - not monotherapy
5. Endoscopic suturing - for massive bleeding marginal ulcers

Note: Forrest Ia/Ib + IIa lesions require endoscopic therapy. Monotherapy with adrenaline alone is no longer recommended - use dual therapy (adrenaline + clip or thermal).

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Step 7 - If Endoscopy Fails or Cannot Be Performed

Interventional Radiology (IR) - Angiographic Embolization:

• CT Angiography (CTA) first - identifies bleeding source if bleed rate ≥0.5 mL/min
• Transcatheter Arterial Embolization (TAE) - preferred over surgery when feasible
• Particularly useful for:
  • Post-gastrectomy vascular erosion/secondary hemorrhage
  • Bleeding marginal ulcer that failed endoscopy
  • Bleeding from named vessels (left gastric, gastroduodenal, splenic artery)
• Success rate: ~70-90% in acute non-variceal UGIB

Surgery (Last Resort):

• Endoscopy failed or not technically feasible
• Angioembolization failed or unavailable
• Massive bleeding - hemodynamically unstable despite resuscitation
• Anastomotic leak with secondary hemorrhage (peritonism + sepsis)
• Erosion into a named vessel (splenic, left gastric, middle colic)

• Gastroenterotomy + transluminal oversewing of bleeding vessel
• Resection of anastomotic region (segmental jejunal resection + additional gastrectomy) - more definitive
• Reoperation carries significantly increased risk - closer to total gastrectomy; underscores importance of non-surgical management first

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Step 8 - Specific Post-Op Considerations

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Management Algorithm Summary

52Y Male, POD 25 Post-Partial Gastrectomy, Coffee Ground Vomitus
                    ↓
        Immediate Assessment: Stable or Unstable?
                    ↓
    ┌───────────────────────────────────────────┐
    │ UNSTABLE                    STABLE        │
    │ → 2x large-bore IV          → 2x IV access│
    │ → Fluid resuscitation       → Labs        │
    │ → ICU admission             → Risk score  │
    │ → Consider intubation       │             │
    └──────────────┬──────────────┘             │
                   ↓                            ↓
         IV PPI + IV Erythromycin 250mg (30 min before scope)
                   ↓
    URGENT UPPER GI ENDOSCOPY (within 12-24h)
                   ↓
    ┌──────────────────────────────────────────────────────┐
    │ Endoscopy reveals:                                   │
    │ • Anastomotic/Marginal ulcer → Forrest classification│
    │   → Dual endoscopic therapy (clip + adrenaline)      │
    │ • Stress ulcer in remnant → Thermal/clip             │
    │ • Mallory-Weiss tear → Usually self-limiting         │
    │ • Anastomotic disruption → Surgical consult          │
    │ • No source found → CTA + Angiography                │
    └──────────────────────────────────────────────────────┘
                   ↓
         Post-endoscopy IV PPI infusion (8 mg/hr × 72h)
                   ↓
         Rebleed? → Repeat endoscopy × 1
                   ↓ (fails)
         IR Angioembolization
                   ↓ (fails)
         Surgery - oversew / anastomotic resection

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Key Points to Remember

1. POD 25 bleed = delayed hemorrhage - most likely cause is anastomotic/marginal ulcer (ischemia, suture material, acid injury to unprotected jejunal mucosa)
2. Coffee grounds = altered blood in gastric acid - not massively brisk, but DO NOT be falsely reassured - it can precede a larger "herald bleed"
3. Endoscopy is both diagnostic and therapeutic - but requires expertise in altered anatomy
4. IV PPI and IV Erythromycin before scope - improves visualization and reduces rebleeding
5. Restrictive transfusion (Hb <7) is preferred in stable patients - shown to reduce mortality
6. Septic secondary hemorrhage must always be considered in the post-gastrectomy patient with signs of sepsis - this is catastrophic and requires IR/surgery
7. Anticoagulants and NSAIDs should be withheld - they do not cause bleeding but can perpetuate it
8. H. pylori - test and treat; long-term PPI after any ulcer complication post-gastrectomy
9. Reoperation carries significant morbidity - always exhaust non-surgical options first

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