Gastroenterology Book

Symptoms Chapter

Anorectal Disorders

Anorectal Pain

Bowel Disorders

Flatulence

Esophageal Disorders

Dysphagia from Esophageal Cause

Hemorrhage

Miscellaneous

Neurology

Hiccup

Peptic Ulcer Disease

Examination Chapter related topics

Upper GI Bleeding Score

Pharmacology Chapter related topics

Simethicone

Surgery Chapter related topics

Postoperative Nausea and Vomiting

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Lower Gastrointestinal BleedingAka: Lower GI Bleed

See Also
1. Gastrointestinal Bleeding
2. Upper Gastrointestinal Bleeding
Causes: Adults with Acute Massive Rectal Bleeding
1. Diverticular bleeding (10-20%)
  1. Increased risk with NSAIDs or Aspirin
  2. Bleeding spontaneously ceases in 75%, recurs in 38%
  3. Recurrence is 9% at one year and 25% at 4 years
2. Angiodysplasia (3-12%)
3. Tumor (2-26%)
4. Inflammatory Bowel Disease (10%)
5. Ischemic Colitis
  1. Seen in vascular disease patients
  2. May be foretold by prior hypotensive event
6. Rectal ulcer (hard stool induced Pressure Ulcers)
7. Acute infectious colitis
8. Pseudomembranous colitis
9. Radiation Colitis
  1. May be delayed 3 years after radiation therapy
10. Post-polypectomy bleeding
  1. Associated with restarting NSAID or Aspirin too soon
11. Aortoenteric fistula (Aortic graft-enteric fistula)
  1. Occurs in those with aortic surgery history
  2. Requires immediate emergency management
12. Internal Hemorrhoid (<10%)
Causes: Adults with chronic intermittent GI Bleeding
1. Hemorrhoids (Up to 59%)
2. Colorectal polyps (38 to 52%)
3. Diverticulosis (34 to 51%)
4. Colorectal Cancer (up to 8%)
5. Ulcerative Colitis
6. Arteriovenous malformations
7. Colonic stricture
Causes: Adults - most commonly missed lower GI sources
1. Arteriovenous malformations
2. Neoplasms in colon
Causes: Children
1. Anal Fissure
2. Infectious colitis
3. Inflammatory Bowel Disease
4. Polyps
5. Intussusception
6. Meckel's Diverticulum
Signs
1. Hematochezia (bright red blood in stool)
  1. Upper gastrointestinal source in 5-11% of patients
2. Nasogastric aspirate clear except for bile
3. Normal Renal Function tests (BUN/Cr)
4. Normal Bowel Sounds
5. Hemodynamic status more stable than in Upper GI Bleed
  1. Orthostasis seen in one third of patients
Labs
1. Hemoglobin or Hematocrit decreased in 50% of patients
  1. Usually less depressed than in Upper GI Bleed
Management: Acute Gastrointestinal Bleeding
1. Avoid tests without adequate yield in acute bleeding
  1. Avoid Flexible Sigmoidoscopy
  2. Avoid Barium Enema
2. Consider Upper Gastrointestinal Bleeding source
  1. Upper GI Bleed with Hematochezia is always unstable
  2. Check Nasogastric aspirate
    1. Will show bile without blood in lower GI source
    2. Duodenal source of Upper GI Bleed may be missed
3. Bleeding ceases spontaneously (occurs in 50% of cases)
  1. See Colonoscopy in GI Bleeding
  2. Evaluation may proceed outpatient in stable patient
  3. Colonoscopy negative: Consider Upper GI Bleed
4. Brisk GI Bleeding obscures source on Colonoscopy
  1. See Angiography in GI Bleeding (preferred)
    1. Test of choice in massive lower GI Bleeding
    2. May direct exploratory laparotomy
  2. See Radionuclide Red Cell Scan (less accurate)
    1. More useful in slower bleeding (<0.4 ml/minute)
    2. Immediate blush identifies high risk bleeding
      1. Ng (1997) Dis Colon Rectum 40:471
5. Slow continuous or recurrent bleeding
  1. See Colonoscopy in GI Bleeding
  2. No source on Colonoscopy
    1. Radionuclide Red Cell Scan: Positive
      1. See Angiography in GI Bleeding
      2. Consider repeat Colonoscopy in GI Bleeding
        
        Guided by red cell scan results
      3. Consider exploratory laparotomy
        
        See below for indications
    2. Radionuclide Red Cell Scan: Negative
      1. Consider Upper Endoscopy
        
        Evaluate for Hematochezia due to Upper GI Bleed
        
        These cases are always hemodynamically unstable
      2. Consider Small Intestinal Bleeding
6. Exploratory laparotomy
  1. Adjunctive intraoperative measures
    1. Intraoperative Colonoscopy
    2. Intraoperative angiography
  2. Indications
    1. Transfusion >4 units in 24 hours
    2. Transfusion >10 units total
    3. Recurrent bleeding episodes
    4. Comorbid conditions significantly affected
Management: Asymptomatic mild rectal bleeding (clinic)
1. Age over 35 years: Colonoscopy
2. Age 25 to 35 years: Diagnostics based on risk factors
3. Age under 25 years: Anoscopy, Flexible Sigmoidoscopy
4. Lewis (2002) Ann Intern Med 136:99
Prognosis
1. Overall mortality <5%
2. Mortality may approach 20% if admitted for comorbidity
References

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