Lower Gastrointestinal Bleeding


Article Author:
Shilpa Amin


Article Editor:
Catiele Antunes


Editors In Chief:
Anantha Padmanabhan
Aakash Gajjar
Burt Cagir


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/11/2019 10:26:25 PM

Introduction

Gastrointestinal (GI) bleeding is a term used for any bleeding that occurs within the GI tract from mouth to anus. GI bleeding can be categorized into upper and lower in origin. The ligament of Treitz is commonly used as the point to differentiate the two. Bleeds proximal to the ligament are upper GI bleeds, and distal bleeds are lower GI bleeds. Categorization into one of the two groups is important as it directs the evaluation and management of the patient.[1][2][3]

Etiology

Lower GI bleeds can be categorized further into three types: massive, moderate, and occult bleeding.[4][5]

Massive bleeding usually occurs in patients older than 65 years with multiple medical problems, and this bleeding presents as hematochezia or bright red blood per rectum. The patient is usually hemodynamically unstable with a systolic blood pressure (SBP) equal to or less than 90 mmHg, heart rate (HR) less than or equal 100/min, and low urine output. Lab work reveals a hemoglobin equal to or less than 6 g/dl. Massive lower GI bleeds are mostly due to diverticulosis and angiodysplasias. The mortality rate may be as high as 21%. 

Moderate bleeding can occur at any age and presents as hematochezia or melena. The patient is usually hemodynamically stable. Many disease processes should be considered on the differential list including neoplastic disease, inflammatory, infectious, benign anorectal, and congenital.

Finally, occult lower GI bleeds can present in patients at any age. Lab work reveals patients with microcytic hypochromic anemia due to chronic blood loss. The differential diagnosis of these patients should include inflammatory, neoplastic and congenital. The patient typically appears well, hemodynamically stable.

Epidemiology

Lower GI bleeds are fairly common and account for 20% to 30% of all patients presenting with major GI bleeding. The incidence is higher in older patients and patients taking multiple medications or multi-pharmacy. Approximately, 80% to 85% of lower GI bleeds originate distal to the ileocaecal valve, with only 0.7% to 9% originating from the small intestine. The remaining cases usually begin in the upper GI tract. These patients usually present with brisk bleeding, melena, or bright red blood per rectum.

Pathophysiology

The diverticular disease accounts for over 40% of lower GI bleeds and often presents as painless hematochezia. More than 80% of lower GI bleeds will stop spontaneously, and overall mortality has been noted to be 2% to 4%. Diverticular bleeding usually recurs. Therefore early identification and management are imperative. The prevalence of diverticular disease increases in elderly patients, particularly ages older than 80 years, patients with chronic constipation, and altered colonic motility. The left colon is often more commonly affected as being the source of diverticular bleeds.

Approximately, one-third of patients with presumed lower GI bleeds and heavy bleeding will have an upper GI bleed, particularly, if the patient presents with signs and symptoms of peptic ulcer disease or recent (non-steroidal anti-inflammatory) NSAID use. Ischemic colitis occurs in 20% of lower GI bleeds and is more prevalent in the elderly. It occurs in response to reduced mesenteric flow to the colon due to decreased cardiac output, vasospasm, or atherosclerotic disease. Non-thrombotic causes usually affect the watershed areas of the bowel, notably, the splenic flexure. These non-occlusive disease processes usually resolve with hydration and nonsurgical intervention. Occlusive or thromboembolic events can affect much larger areas of the bowel and should be quickly evaluated with mesenteric angiography. Patients with mesenteric ischemia require radiographic and/or surgical evaluation and intervention.

The most common cause of lower GI bleeds in patients younger than 50 years is anorectal disorders, specifically, hemorrhoids. Inflammatory bowel disease (IBD) and NSAID use should also be evaluated in lower GI bleeds. Other disease processes practitioners should consider include vascular ectasias which are flat, red mucosal lesions in the cecum and ascending colon and represent 10% of lower GI bleeds. Post-polypectomy bleeding is more common in patients older than 65 years with a polyp greater than 1 cm. Bleeding is usually self-limited but can be delayed up to one week after the procedure. 

History and Physical

Patients presenting with lower GI bleeds can have varying symptoms and signs. Therefore a thorough history is necessary. Patients can present with scant bleeding to massive hemorrhage. Key details in the history should include whether the bleeding is recurrent or sporadic if there are associated symptoms and a detailed review of the patient's medications including, antiplatelets, anticoagulants, and NSAIDs. The family history of colon cancer or inflammatory bowel disease (IBD) should also be noted.

Abdominal examination and digital rectal examination should be completed in all patients presenting with lower GI bleeds. If available, consider proctoscopy as well. Abdominal examination may reveal tenderness, distension, or a mass depending on the cause. When completing the digital rectal examination (DRE) inspect for hematochezia and anorectal pathology, such as hemorrhoids. Studies reveal that left colonic bleeding tends to be bright red, whereas right colonic is usually maroon and may be accompanied with clots. However noted in practice, bright red blood per rectum can occur in right-sided bleeds that are brisk and massive.

Evaluation

All patients presenting with a lower GI bleed should be triaged and evaluated immediately and consistently as patients with GI bleeding can decompensate fairly quickly. As with all potential medical resuscitations, the patient's airway and respiratory status should be evaluated first. If there is a concern for the patient's airway, a definitive airway should be secured first. If the patient is maintaining their airway but has had a significant amount of melena or signs of shock, then an airway set up should be nearby as these patients can decompensate rapidly.[6][4][7][8]

During initial evaluation and triage, supplemental oxygen, the establishment of two, large-bore peripheral intravenous (IV) drip feeds, and placement on a cardiopulmonary monitor is a standard approach. An IV infusion of crystalloid can be started immediately to resuscitate a patient. Transfusions should be considered during resuscitation guided by the patient presentation, clinical course, and literature.

Labwork should include a complete blood count (CBC), electrolyte evaluation, liver function tests, lactate levels, and coagulation studies if the patient is on medications that would cause them to be coagulopathic.

The BLEED criteria are able to be applied to any patient with a GI bleed (upper or lower) and easy to remember. The criteria are listed below:

Ongoing Bleeding: Red bloody emesis / NG aspirate or spontaneous passage of red/maroon blood (not counting formed stool)

Low Systolic Blood Pressure: Less than 100 mmHg not counting orthostatic readings

Elevated Prothrombin Time: Greater than 1.2 times normal

Erratic Mental Status: Any altered level of consciousness from any cause.

Unstable Comorbid Disease: Another disease process that would warrant intensive care unit (ICU) admission without the presence of a GI bleed.

The presence of any one factor is considered high-risk with patients having been proven to have a significantly higher risk of in hospital complications. When using the BLEED criteria, it is important to know what was considered positive criteria when studied. Active/ongoing upper GI bleeding was defined as red blood by emesis or nasogastric tube, while coffee ground emesis/nasogastric aspirate was not considered active/ongoing bleeding. Active lower GI bleeding was considered the presence of spontaneous passing of red or maroon blood from the rectum, while formed maroon or black stool was not considered to represent active bleeding. A low systolic blood pressure (SBP) is when the patient's systolic blood pressure is less than 100 mmHg, not including orthostatic readings. The prothrombin time is considered elevated when it is more than 1.2 times the normal. A mental status was considered erratic if there was any documentation of altered consciousness, even if attributable to a secondary cause such as drugs. The unstable comorbid disease criterion was not well defined and was considered the presence of another disease process that would warrant ICU admission in the absence of a GI bleed.

Treatment / Management

Colonoscopy has been shown to correctly identify the source of lower GI bleeds in more than 75% of patients while also allowing a therapeutic modality. The timing of the colonoscopy remains controversial. However, most studies suggest it should be performed within the first 24 hours of admission, following bowel prep of the patient. Treatments for diverticular bleeds include the injection of adrenaline (1:10000) in 1 mL to 2mL aliquots at the site. If the patient is not stable enough for a colonoscopy, then radiologic evaluation should be considered. CT angiography (CTA) is relatively noninvasive, fast and widely available. CTA can detect bleeding rates more than .3 mL/min to .5 mL/min. CTA, however, has a relatively low sensitivity (85%). Catheter angiography is reserved for patients with hemodynamic instability who cannot tolerate a colonoscopy or have recurrent bleeding. Radionuclide imaging uses Technetium (99mTc) based tracers to tag red blood cells and is helpful in detecting scant intermittent bleeding.  The half-life of 99mTc is long so the scan can be repeated several times in a 24-hour period to evaluate sequential images. [9][10][11]Surgery may be required if radiologic and endoscopic procedures fail. It is best to consult a colorectal surgeon early in the diagnostic evaluation of the patient as these patients and become unstable fairly quickly.  In patients with hemodynamic instability, requiring more than six units of blood within 24 hours, or not responding to resuscitation attempts, emergency segmental resection or subtotal colectomy may be required.[12][13]

Enhancing Healthcare Team Outcomes

Patients with a LGIB usually present to the emergency department. Because there are many causes of a LGIB the disorder is best managed by a multidisciplinary team that includes a surgeon, gastroenterologist, radiologist, intensivist and the emergency department physician. Depending on the severity of the bleed, these patients may require admission to the ICU and monitoring by the nurses. Some of these patients may require resuscitation including blood transfusions. Imaging studies are useful to find the location of the bleeding but some patients may need emergency surgery to stop the bleeding. The outcomes of patients with LGIB depends on the age of the patient, other comorbidity, hemodynamic stability and the need for emergent surgery.[14][15] (Level V)


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Lower Gastrointestinal Bleeding - Questions

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Which of the following is not appropriate for a patient who is hypotensive due to a lower gastrointestinal bleed?



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A 59-year-old male who smokes cigarettes and has a history of hemorrhoids complains of bright red blood on the toilet paper during bowel movements. Which of the following is not an accepted part of the initial management?



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A 65-year-old male presents with massive bright red blood per rectum that started today. His blood pressure is 80/49 and his heart rate is 115. What is the first step in the management of this patient?



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What is the most sensitive technique for detection of a lower gastrointestinal bleed?



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Which of the following is not true about lower gastrointestinal hemorrhage with hemodynamic consequences?



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Which of the following is the next best step in management of lower GI bleeding that is not visible by colonoscopy?



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What is the best management for a 70-year-old who presents with 5 hours of hematochezia and dropping hemoglobin who is hemodynamically stable?



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Select the most common etiology for massive lower gastrointestinal hemorrhage.



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A 43-year-old female presents to the emergency department with 4 large volume bloody stools over the past day without abdominal pain. She has no significant past medical history. Her blood pressure drops from 130/80 mm Hg lying to 95/65 mm Hg sitting. Her heart rate increases from 100 to 120 bpm. The abdomen is nontender while the rectal exam shows no masses but there is bright red blood in the vault. NG lavage shows no blood. CBC shows hemoglobin of 8.5 g/dL. Normal saline is started at 200 cc/hour and an infusion of 3 units of packed red blood cells is started. The heart rate drops to 90 bpm and the orthostasis improves. Which of the following tests would be least appropriate?



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What is the best initial management of a child with a significant lower gastrointestinal bleeding?



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All of the following are true about lower gastrointestinal hemorrhage with hemodynamic consequences except which of the following?



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A patient is on warfarin for a valve replacement. Her INR is 15. She has rectal bleeding. What is the best approach?



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An 80-year-old patient presents to the emergency department with his family for melena, abdominal pain, and feeling weak and tired. The symptoms occurred after he started a new medication for his irregular heart beat. Vital signs are temperature 36 C, blood pressure 140/76 mmHg, heart rate 113 bpm, and pulse oximetry 94%. What is the best initial management?



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A 58-year-old patient presents to the emergency department unresponsive. She told her family that she has been having increasing pain to her rectum for the past three months. On physical exam, the patient winces with pain to palpation to the left lower quadrant. Rectal exam reveals melanotic stools and crackles to bilateral lung fields. Vital signs are temperature 36 C, heart rate 126 bpm, blood pressure 103/48 mmHg, and pulse oximetry 86% on room air. What are the next steps in evaluating this patient?



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Lower Gastrointestinal Bleeding - References

References

Kim ER,Chang DK, Management of Complications of Colorectal Submucosal Dissection. Clinical endoscopy. 2019 Mar;     [PubMed]
Shafqet MA,Tonthat A,Esparragoza P,Toro B,Ehrlich AC,Friedenberg FK, Recent use of NSAID and NOAC medications are associated with a positive CT arteriogram. Abdominal radiology (New York). 2019 Apr 4;     [PubMed]
Rawla P,Devasahayam J, Mallory Weiss Syndrome 2019 Jan;     [PubMed]
Jung K,Moon W, Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review. World journal of gastrointestinal endoscopy. 2019 Feb 16;     [PubMed]
Mizuki A,Tatemichi M,Nagata H, Management of Diverticular Hemorrhage: Catching That Culprit Diverticulum Red-Handed! Inflammatory intestinal diseases. 2018 Dec;     [PubMed]
Oakland K,Chadwick G,East JE,Guy R,Humphries A,Jairath V,McPherson S,Metzner M,Morris AJ,Murphy MF,Tham T,Uberoi R,Veitch AM,Wheeler J,Regan C,Hoare J, Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut. 2019 Feb 12;     [PubMed]
Machlab S,García-Iglesias P,Martínez-Bauer E,Campo R,Calvet X,Brullet E, Diagnostic utility of nasogastric tube aspiration and the ratio of blood urea nitrogen to creatinine for distinguishing upper and lower gastrointestinal tract bleeding. Emergencias : revista de la Sociedad Espanola de Medicina de Emergencias. 2018 Dic;     [PubMed]
Nagata N,Ishii N,Manabe N,Tomizawa K,Urita Y,Funabiki T,Fujimori S,Kaise M, Guidelines for Colonic Diverticular Bleeding and Colonic Diverticulitis: Japan Gastroenterological Association. Digestion. 2019;     [PubMed]
Nagashima K,Tominaga K,Fukushi K,Kanamori A,Sasai T,Hiraishi H, Recent trends in the occurrence of bleeding gastric and duodenal ulcers under the Japanese evidence-based clinical practice guideline for peptic ulcer disease. JGH open : an open access journal of gastroenterology and hepatology. 2018 Dec;     [PubMed]
Sengupta N,Cifu AS, Management of Patients With Acute Lower Gastrointestinal Tract Bleeding. JAMA. 2018 Jul 3;     [PubMed]
Almadi MA,Barkun AN, Patient Presentation, Risk Stratification, and Initial Management in Acute Lower Gastrointestinal Bleeding. Gastrointestinal endoscopy clinics of North America. 2018 Jul;     [PubMed]
Oakland K,Jairath V,Murphy MF, Advances in transfusion medicine: gastrointestinal bleeding. Transfusion medicine (Oxford, England). 2018 Apr;     [PubMed]
Díaz AM,Rodríguez LF,de Gracia MM, Is urgent CT angiography necessary in cases of acute lower gastrointestinal bleeding? Radiologia. 2017 May - Jun;     [PubMed]
Fok KY,Murugesan JR,Maher R,Engel A, Management of per rectal bleeding is resource intensive. ANZ journal of surgery. 2019 Apr;     [PubMed]
Kherad O,Restellini S,Martel M,Sey M,Murphy MF,Oakland K,Barkun A,Jairath V, Outcomes following restrictive or liberal red blood cell transfusion in patients with lower gastrointestinal bleeding. Alimentary pharmacology     [PubMed]

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