Case Study: Acute Hematochezia in a 39-Year-Old Female with Recent NSAID Use

Case at a Glance

A 39-year-old female presented to the emergency department with an acute onset of bloody stools. An initial examination ruled out common anorectal causes, and her recent use of a nonsteroidal anti-inflammatory drug (NSAID) became a key factor in the diagnostic process.

Patient's Story

A 39-year-old female, otherwise in good health, presented to the emergency department with significant anxiety after experiencing two episodes of bloody bowel movements on the morning of admission. She described the blood as being mixed with very loose stool and also appearing at the end of defecation. The patient likened the appearance of the blood to 'clotted menstrual blood.' She noted that loose stools are a baseline for her. Her regular medication includes Sertraline 50 mg daily for a pre-existing condition. She also reported taking ibuprofen the previous night for a headache.

Initial Assessment

Upon arrival at the emergency department, the patient was alert and hemodynamically stable, though visibly distressed. A physical examination, including a digital rectal exam, was performed. The examination revealed no external or internal hemorrhoids, anal fissures, or palpable rectal masses. The history highlighted the acute nature of the bleeding and the absence of other systemic symptoms like fever, significant abdominal pain, or weight loss.

The Diagnostic Journey

The initial differential diagnosis for hematochezia in this age group included infectious colitis, inflammatory bowel disease (IBD), diverticulitis, and arteriovenous malformations (AVMs). While malignancy is always a consideration, it was deemed less likely given the patient's age and acute presentation. The history of recent ibuprofen use was a significant finding, raising suspicion for NSAID-induced colitis or enteropathy, which can cause ulceration and bleeding in the gastrointestinal tract. The emergency physician reassured the patient that while further investigation was necessary, causes other than cancer were more probable. Initial blood tests were ordered to check hemoglobin levels and inflammatory markers.

Final Diagnosis

Working Diagnosis: Suspected NSAID-induced Colitis.

Treatment Plan

The immediate management in the emergency department focused on stabilization and investigation. The patient was advised to immediately discontinue the use of all NSAIDs, including ibuprofen. She was counseled on the potential link between the medication and her symptoms. She was discharged with strict instructions to return if she experienced further bleeding, dizziness, or severe abdominal pain. A referral was made for an urgent follow-up with her primary care physician to arrange for a colonoscopy to visualize the colon, confirm the diagnosis, and rule out other pathologies.

Outcome and Follow-up

The patient was discharged in stable condition. Her follow-up plan includes a consultation with her GP within the week to schedule an outpatient colonoscopy. The expected outcome is a resolution of bleeding upon cessation of NSAIDs. The colonoscopy will be crucial for confirming the diagnosis and guiding any further management if another cause is identified.