84 yo lady for gastroscopy and colonoscopy

Background

• CVA – presumed cardioembolic
• PAF – DOAC
• Fe deficiency anaemia – chronic
  • AV malformation in small bowel
  • Managed with iron infusions
• CKD – stage 1
• Intracerebral aneurysm – under surveillance
• IHD – stented

Issues

• Melaena and anaemia – DOAC for CVA. Hb drop from 112 to 53.
• Previous gas/colon showed healed antral ulcer. 
  • Complicated by hypotension. Treated IVF and vasopressors. 
  • Required ICU for fluid overload.
  • Patient doesn’t want to have procedure – worried about having further cardiac failure, stroke, and ICU admission.
  • Patient concerns reasonable, unclear cause of previous event

Discussion

Proceed to surgery?

• Reasonable to proceed to gastroscopy –
  • low risk for fluid overload. 
• Colonoscopy – indication unclear
• More fluid shifts involved.
• RFA indication for colonoscopy states haemorrhoids
  • Consider less invasive investigations? Eg. proctoscopy/flexible sigmoidoscopy

Plan

• Proceed with gastroscopy only at this stage – avoid bowel prep and significant fluid shifts
• Liaise with surgical team regarding colocoscopy