Lower gastrointestinal bleeding

Changed by Henry Knipe, 28 Jul 2014
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Lower gastrointestinal bleeding (LGIB) is defined as that occurring distal to the ligament of Treitz (i.e. from the jejunum, ileum, colon, rectum or anus) and presenting as either haematochezia (bright red blood/clots or burgundy stools) or melaena 1.

Epidemiology

The incidence of LGIB is only one-fifth that of the upper gastrointestinal tract and is estimated to be ~24 per 100,000 000 adults per year. Male and older patients tend to suffer from more severe LGIB 3. 

Clinical presentation

Acute bleeding is defined as bleeding of <3 days duration resulting in instability of vital signs, anemia and/or the need for blood transfusion 3. 

Chronic bleeding is defined as slow blood loss over a period of several days or longer, presenting with symptoms of occult faecal blood, intermittent melaena or scant hematochezia 3. 

LGIB usually is chronic and the bleeding ceases spontaneously (80%) 3.

Pathology

Aetiology

Although LGIB can occur at any age, specific disease processes are distinctive for different age groups and familiarity with this can help tailor the diagnostic workup. The source of LGIB for different age groups are listed below 2:

See article: lower gastrointestinal bleeding (differential diagnosis).

Risk factors

Risk factors include 1: 

  • medications (e.g. NSAID, warfarin)
  • recent colonoscopy with polypectomy (postpolypectomy bleeding)
  • prior abdominal/pelvic radiation (radiation proctitis/colitis)
  • prior operation
  • history of alcoholism or chronic liver disease
  • history of abdominal aortic aneurysm with or without surgical repair (aorto-enteric fistula)

Radiographic features

Colonoscopy is the first-line investigation of both diagnostic and therapeutic management.

CT Angiography (CTA)

CTA provides a quick, relatively non-invasive and effective way of localising the source of bleeding, especially in the patient with continued bleeding 5.

Studies have looked at the use of CTA in the localisation of GI hemorrhage report sensitivity of ~90% when there is active bleeding, but are considerably lower when the bleeding is intermittent in nature with rates reported at ~45% 1.

Again, contraindications apply to patients with renal failure who are at risk of developing contrast-induced nephropathy 1.

Nuclear medicine

Involves labeling erythrocytes with technetium-99m and then performing serial scintigraphy (also known as a tagged red blood cell scan) to detect focal collections of radiolabeled material. It can be performed relatively quickly and may help localize the general area of bleeding to guide subsequent endoscopy, angiography or surgery 1. 

False-positive result can be produced by rapid transit of luminal blood, so that labeled blood is detected in the colon even though it originate from a more primal site in the GI tract 1. Radionuclide imaging can only detect active bleeding.

Angiography

Angiography can provide the opportunity for therapeutic intervention at the time of diagnosis and able to perform a provocative test to aid with localization of intermittent bleed 1, 2. 

However, the bleeding rate must be at least 0.5 mL/min to detect extravasation into the gut, which is significantly higher than in nuclear medicine. Additionally, certain patient factors (e.g. contrast allergy, acute/chronic kidney disease) are potential contraindications to angiography 1. 

  • -<p><strong>Lower gastrointestinal bleeding (LGIB) </strong>is defined as that occurring distal to the ligament of Treitz (i.e. from the jejunum, ileum, colon, rectum or anus) and presenting as either haematochezia (bright red blood/clots or burgundy stools) or melaena <sup>1</sup>.</p><h4>Epidemiology</h4><p>The incidence of LGIB is only one-fifth that of the upper gastrointestinal tract and is estimated to be ~24 per 100,000 adults per year. Male and older patients tend to suffer from more severe LGIB <sup>3</sup>. </p><h4>Clinical presentation</h4><p>Acute bleeding is defined as bleeding of &lt;3 days duration resulting in instability of vital signs, anemia and/or the need for blood transfusion <sup>3</sup>. </p><p>Chronic bleeding is defined as slow blood loss over a period of several days or longer, presenting with symptoms of occult faecal blood, intermittent melaena or scant hematochezia <sup>3</sup>. </p><p>LGIB usually is chronic and the bleeding ceases spontaneously (80%) <sup>3</sup>.</p><h4>Pathology</h4><h5>Aetiology</h5><p>Although LGIB can occur at any age, specific disease processes are distinctive for different age groups and familiarity with this can help tailor the diagnostic workup. The source of LGIB for different age groups are listed below <sup>2</sup>:</p><ul>
  • -<li>adolescents and young adults: <a title="Inflammatory bowel disease" href="/articles/inflammatory-bowel-disease">inflammatory bowel disease</a>, polyps, <a href="/articles/meckels-diverticulum">Meckel's diverticulum</a>
  • +<p><strong>Lower gastrointestinal bleeding (LGIB) </strong>is defined as that occurring distal to the ligament of Treitz (i.e. from the jejunum, ileum, colon, rectum or anus) and presenting as either haematochezia (bright red blood/clots or burgundy stools) or melaena <sup>1</sup>.</p><h4>Epidemiology</h4><p>The incidence of LGIB is only one-fifth that of the upper gastrointestinal tract and is estimated to be ~24 per 100 000 adults per year. Male and older patients tend to suffer from more severe LGIB <sup>3</sup>. </p><h4>Clinical presentation</h4><p>Acute bleeding is defined as bleeding of &lt;3 days duration resulting in instability of vital signs, anemia and/or the need for blood transfusion <sup>3</sup>. </p><p>Chronic bleeding is defined as slow blood loss over a period of several days or longer, presenting with symptoms of occult faecal blood, intermittent melaena or scant hematochezia <sup>3</sup>. </p><p>LGIB usually is chronic and the bleeding ceases spontaneously (80%) <sup>3</sup>.</p><h4>Pathology</h4><h5>Aetiology</h5><p>Although LGIB can occur at any age, specific disease processes are distinctive for different age groups and familiarity with this can help tailor the diagnostic workup. The source of LGIB for different age groups are listed below <sup>2</sup>:</p><ul>
  • +<li>adolescents and young adults: <a href="/articles/inflammatory-bowel-disease">inflammatory bowel disease</a>, polyps, <a href="/articles/meckels-diverticulum">Meckel's diverticulum</a>
  • -<li>up to 60 years: <a href="/articles/diverticulum">diverticula</a>, <a title="Inflammatory bowel disease" href="/articles/inflammatory-bowel-disease">inflammatory bowel disease</a>, malignancy</li>
  • +<li>up to 60 years: <a href="/articles/diverticulum">diverticula</a>, <a href="/articles/inflammatory-bowel-disease">inflammatory bowel disease</a>, malignancy</li>
  • -</ul><p>See article: <a title="Lower gastrointestinal bleeding - differential diagnosis" href="/articles/lower-gastrointestinal-bleeding-haemorrhage-differential-diagnosis">lower gastrointestinal bleeding (differential diagnosis)</a>.</p><h5>Risk factors</h5><p>Risk factors include <sup>1</sup>: </p><ul>
  • +</ul><p>See article: <a href="/articles/lower-gastrointestinal-bleeding-haemorrhage-differential-diagnosis">lower gastrointestinal bleeding (differential diagnosis)</a>.</p><h5>Risk factors</h5><p>Risk factors include <sup>1</sup>: </p><ul>
  • -<li>history of <a title="Abdominal aortic aneurysm" href="/articles/abdominal_aortic_aneurysm">abdominal aortic aneurysm</a> with or without surgical repair (aorto-enteric fistula)</li>
  • +<li>history of <a href="/articles/abdominal-aortic-aneurysm">abdominal aortic aneurysm</a> with or without surgical repair (aorto-enteric fistula)</li>
Images Changes:

Image 3 CT (C+ portal venous phase) ( create )

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