Lower Gastrointestinal Hemorrhage
Lower gastrointestinal bleeding refers to bleeding from a source distal to the ligament of Treitz. Presentation ranges from occult bleeding with anemia to frank hemorrhage with cardiovascular collapse. Management hinges on volume resuscitation and restora
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Key Concepts
Introduction
• Common etiologies of lower gastrointestinal hemorrhage include diverticular disease, angioectasia, ischemic colitis, and neoplasm. • The primary consideration in managing the patient with acute lower gastrointestinal hemorrhage is ensuring adequate volume resuscitation. • Patients presenting with massive lower gastrointestinal bleeding should be evaluated for upper gastrointestinal and anorectal sources via gastric lavage and anoscopy/proctoscopy. • Screening for active bleeding via CT angiography or 99m Tc-RBC scan increases the likelihood of identifying active bleeding on mesenteric angiography. • An active bleeding source seen on mesenteric angiography can often be managed with superselective transcatheter embolization. • The patient with a self-limited major lower gastrointestinal hemorrhage that has stopped should undergo colonoscopy for further evaluation after a mechanical bowel prep. • In certain circumstances, colonoscopy for the evaluation of active lower gastrointestinal bleeding may be considered; if active bleeding is encountered, therapeutic options include clipping, injection, and argon plasma coagulation. • The unstable patient with uncontrolled, unlocalized lower gastrointestinal hemorrhage should undergo a total abdominal colectomy, in most cases with an ileostomy. • The patient with ongoing or recurrent hemorrhage from a localized lower gastrointestinal source may be managed with a targeted, segmental resection. • Clinical pathways and predictive models may help better guide the management of patients with acute lower gastrointestinal hemorrhage, limiting unnecessary admissions and optimizing the use of resources.
Lower gastrointestinal bleeding (LGIB) refers to the passage of visible blood from the rectum and classically originates from a source distal to the ligament of Treitz. This distressing condition challenges both the clinician and patient, as LGIB may potentially arise from anywhere along a large anatomic distribution, may result from an array of pathologic conditions, can vary widely in severity, and frequently stops spontaneously prior to definitive diagnosis. In fact, no definitive source is found in approximately 10% of all cases of LGIB [1–3]. Descriptions reported by patients and witnesses can offer a spectrum of qualifiers in regard to the volume, color, associated symptoms, and hemodynamic consequences. The patient and family often experience significant stress and emotion by the sight of any significant quantity of blood passing from the rectum and likely experience an understandable sense of urgency to seek rapid medical evaluation and treatment. Thus, it is not uncommon for patients to present to emergency departments with less serious degrees of rectal bleeding. In fact, a report from an urban medical center reviewed over 1100 patients admitted for LGIB and found that over 20% of their hospitalized patients ultimately were identified to have a diagnosis of hemorrhoids [4]. The financial burden of LGIB per hospitalization ranges from $9700 to $11
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