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Lower Gastrointestinal Bleeding Clinical Presentation

  • Author: Burt Cagir, MD, FACS; Chief Editor: BS Anand, MD  more...
 
Updated: Mar 29, 2016
 

History

History and physical examination are essential parts of an initial evaluation of lower gastrointestinal bleeding (LGIB). These can provide valuable clues to the etiology and anatomical source of bleeding. Document whether this is a first or recurrent episode of gastrointestinal (GI) bleeding as well as significant medical history (including peptic ulcer disease, liver disease, cirrhosis, coagulopathy, inflammatory bowel disease [IBD]) and previous medication use (eg, nonsteroidal anti-inflammatory drugs (NSAIDs) and/or warfarin). In patients with cancer, the history of radiation, chemotherapy, or both should be considered.

The clinical presentation of LGIB varies with the anatomical source of the bleeding as well as with the etiology. Commonly, LGIB from the right side of the colon can manifest as maroon stools, whereas a left-sided bleeding source may be evidenced by bright red blood per rectum. In practice, however, patients with upper GI bleeding (UGIB), and right-sided colonic bleeding may also present with bright red blood per rectum if the bleeding is brisk and massive. Similarly, cecal bleeding may present with melena, which is typically seen with UGIB, suggesting no distinct method exists for determining the anatomic source of bleeding based solely on stool color.

The presentation of LGIB can also vary depending on the etiology. A young patient may present with fever, dehydration, abdominal cramps, and hematochezia caused by infectious or noninfectious (idiopathic) colitis. An older patient may present with painless bleeding and minimal symptoms caused by diverticular bleeding or angiodysplasia. LGIB can be mild and intermittent, as often is the case with angiodysplasia, or moderate or severe, as may be the situation in diverticula-related bleeding.

Symptoms are also important in identifying the source of bleeding. Young patients may present with abdominal pain, rectal bleeding, diarrhea, and mucous discharge that may be associated with IBD. However, elderly patients presenting with abdominal pain, rectal bleeding, and diarrhea may have ischemic colitis, or elderly patients with atherosclerotic heart disease may present with intermittent LGIB and syncope that may be due to angiodysplastic lesions. Stools streaked with blood, perianal pain, and blood drops on the toilet paper or in the toilet bowl may be associated with perianal pathology, such as anal fissure or hemorrhoidal bleeding.

Massive lower GI bleeding is a life-threatening condition in which patients present with a systolic blood pressure of less than 90 mm Hg and a hemoglobin (Hb) level of 6 g/dL or less. These patients are usually aged 65 years and older, have multiple medical problems, and are at risk of death from acute hemorrhage or its complications. The passage of maroon stools or bright red blood from the rectum is usually indicative of massive lower GI hemorrhage.

Diverticular bleeding

Although diverticular bleeding is painless, patients may experience mild abdominal cramping due to the intraluminal blood that triggers spasmodic contraction of the colonic wall. Bleeding is usually acute, without antecedent symptoms, and is self-limited in about 70-80% of cases. Rebleeding can occur in up to 25% of patients.[21]

If the bleeding is brisk and voluminous, patients may be hypotensive and display signs of shock. Clinical recommendations for diverticular bleeding published by the American Academy of Family Physicians (AAFP) in 2009 state that bleeding or unstable vital signs require rapid assessment and resuscitation before diagnostic testing.[22]

Chronic, intermittent, minimal blood loss per rectum is unlikely to be caused by diverticular bleeding, because diverticular bleeding is arterial in origin.

Angiodysplasia

Significant angiodysplasia-related bleeding, like diverticular bleeding, presents as painless, self-limited hematochezia or melena; angiodysplasia-related bleeding is venocapillary. Unlike diverticular bleeding, angiodysplasia tends to cause slow but repeated episodes of bleeding. Therefore, patients may present with Hemoccult-positive stools, iron-deficiency anemia, and syncope. Occasionally, patients can present with bleeding of large quantities.

Colitis

Ischemic colitis may or may not present with abdominal pain and associated bloody diarrhea. The bloody diarrhea is self-limited but can recur if the underlying cause is not corrected. Although the clinical presentation is indistinguishable at times from that of infectious colitis, idiopathic colitis, and radiation-induced colitis, patients with ischemic colitis are usually older with cardiovascular comorbidities. Ischemic colitis may be fulminant, presenting with acute abdominal pain, rectal bleeding, and hypotension, or this condition may be insidious, presenting with pain and rectal bleeding over several weeks.

In infectious colitis, the clinical examination findings vary depending on the volume status, amount of blood loss, extent of abdominal pain, and accompanying peritoneal signs. The clinical presentation of fever, diarrhea, dehydration, and abdominal pain can be caused by any of a number of bacterial, viral, or parasitic pathogens. The specific etiology can only be determined by isolating the organism from the stool, blood, or other tissue fluid. Patients may be quite ill and may experience intravascular volume depletion, abdominal pain, and generalized malaise, but blood loss is usually mild and a minor factor in symptomatology.

The clinical presentation of ulcerative colitis depends on whether the disease is mild, moderate, or severe. Although bleeding is minimal to none in people with mild disease, those with moderate-to-severe ulcerative colitis present with bloody diarrhea with pus, abdominal cramps, and dehydration. Symptoms of weight loss and fever occur in those with severe disease. Patients with Crohn disease usually present with fever, nonbloody diarrhea, and abdominal pain. However, patients with Crohn colitis can present with bloody diarrhea.

Colon carcinoma

The bleeding associated with colon cancer, particularly right-sided bleeding, can be insidious, with patients presenting with iron-deficiency anemia and syncope. Right-sided colon cancer may also present with maroon-colored stools or melena, whereas left-sided colonic cancers can present as bright red blood per rectum, which can sometimes be confused with hemorrhoidal bleeding.

Anorectal disease

Hemorrhoidal bleeding is most often painless, whereas bleeding secondary to fissures tends to be painful. Hemorrhoids can also present with strangulation, hematochezia, and pruritus. Typically, bright red blood coats the stool at the end of defecation or blood may stain the toilet paper. Rarely, the bleeding may be copious, distressing to the patient.

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Physical Examination

The physical examination should be thorough and include the skin, oropharynx, nasopharynx, abdomen, perineum, and anorectum to evaluate for sources of bleeding.

Because brisk UGIB can present as LGIB, a nasogastric (NG) tube may be necessary and the aspirate or lavage examined for the presence of blood and bile. These aspirates usually correlate well with upper gastric hemorrhage proximal to the Treitz ligamentum; therefore, insert an NG tube to confirm the presence or absence of blood in the stomach.

If necessary, perform gastric lavage with warm isotonic fluids to obtain bilious discharge; an aspirate that is positive for bile is comprehensive in that it includes fluid even beyond the pylorus. In such a scenario, if no blood is present, a UGIB source only makes sense if the bleeding has stopped. If this possibility exists, an esophagogastroduodenoscopy (EGD) should be performed to obtain a more specific evaluation of the upper GI tract. Place a Foley catheter to monitor urine output. Careful digital rectal examination, anoscopy, and rigid proctosigmoidoscopy should exclude an anorectal source of bleeding.

Patients who have rectal varices with portal hypertension may develop painless massive LGIB; therefore, examining the anorectum early in the workup is important. If active bleeding is identified, treat it aggressively. Note that the discovery of benign anorectal disease does not exclude the possibility of more proximal bleeding from the lower GI tract.

Once the bleeding is determined to be from the lower GI tract as opposed to an upper GI source, the tempo of the bleeding and the extent of blood loss should be quickly estimated so that a precise and targeted algorithm is adopted (see an example in the image below). Patients with massive LGIB usually present with bright red blood per rectum, hypotension, and a markedly reduced hematocrit as opposed to patients with mild bleeding who may present with intermittent passage of maroon-colored stools. The emergency implementation of aggressive resuscitation, diagnostic evaluation, and early involvement of a gastroenterologist (and surgeon in the case of a rapid LGIB) is key to reducing the morbidity and mortality and to improving outcomes.

Algorithm for massive lower gastrointestinal (GI) Algorithm for massive lower gastrointestinal (GI) bleeding, surgical perspective. EGD = esophagogastroduodenoscopy; NG = nasogastric; 99mTc RBC = technetium-99m pertechnetate–labeled autologous RBC.
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Contributor Information and Disclosures
Author

Burt Cagir, MD, FACS Clinical Professor of Surgery, The Commonwealth Medical College; Attending Surgeon, Assistant Program Director, Robert Packer Hospital; Attending Surgeon, Corning Hospital

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Coauthor(s)

Elizabeth Cirincione, MD Director of Colon and Rectal Surgery, Department of Surgery, Nassau University Medical Center

Elizabeth Cirincione, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Gavin F Chico, MD Consulting Staff, CHRISTUS Coushatta Rural Health Clinic

Disclosure: Nothing to disclose.

Kenneth J Manas, MD Assistant Professor, Department of Medicine, Section of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center

Kenneth J Manas, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Marc D Basson, MD, PhD, MBA, FACS Associate Dean for Medicine, Professor of Surgery and Basic Science, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

David Greenwald, MD Professor of Clinical Medicine, Fellowship Program Director, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, New York Society for Gastrointestinal Endoscopy, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

References
  1. Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol. 2003 Jan. 13(1):114-7. [Medline].

  2. Yamaguchi T, Yoshikawa K. Enhanced CT for initial localization of active lower gastrointestinal bleeding. Abdom Imaging. 2003 Sep-Oct. 28(5):634-6. [Medline].

  3. Talley NJ, Jones M. Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking. Am J Gastroenterol. 1998 Nov. 93(11):2179-83. [Medline].

  4. Qayed E, Dagar G, Nanchal RS. Lower gastrointestinal hemorrhage. Crit Care Clin. 2016 Apr. 32 (2):241-54. [Medline].

  5. Baum S, Nusbaum M, Blakemore WS, Finkelstein AK. The preoperative radiographic demonstration of intra-abdominal bleeding from undetermined sites by percutaneous selective celiac and superior mesenteric arteriography. Surgery. 1965 Nov. 58(5):797-805. [Medline].

  6. Rosch J, Gray RK, Grollman JH Jr, et al. Selective arterial drug infusions in the treatment of acute gastrointestinal bleeding. A preliminary report. Gastroenterology. 1971. 59(3):341-9.

  7. Rösch J, Dotter CT, Brown MJ. Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology. 1972 Feb. 102(2):303-6. [Medline].

  8. Meyers MA, Alonso DR, Gray GF, Baer JW. Pathogenesis of bleeding colonic diverticulosis. Gastroenterology. 1976 Oct. 71(4):577-83. [Medline].

  9. Vernava AM, Longo WE, Virgo KS. A nationwide study of the incidence and etiology of lower gastrointestinal bleeding. Surg Res Commun. 1996. 18:113-20.

  10. Gayer C, Chino A, Lucas C, Tokioka S, Yamasaki T, Edelman DA, et al. Acute lower gastrointestinal bleeding in 1,112 patients admitted to an urban emergency medical center. Surgery. 2009 Oct. 146(4):600-6; discussion 606-7. [Medline].

  11. Vernava AM 3rd, Moore BA, Longo WE, Johnson FE. Lower gastrointestinal bleeding. Dis Colon Rectum. 1997 Jul. 40(7):846-58. [Medline].

  12. Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1997 Mar. 92(3):419-24. [Medline].

  13. Gupta N, Longo WE, Vernava AM 3rd. Angiodysplasia of the lower gastrointestinal tract: an entity readily diagnosed by colonoscopy and primarily managed nonoperatively. Dis Colon Rectum. 1995 Sep. 38(9):979-82. [Medline].

  14. Saperas E, Videla S, Dot J, Bayarri C, Lobo B, Abu-Suboh M, et al. Risk factors for recurrence of acute gastrointestinal bleeding from angiodysplasia. Eur J Gastroenterol Hepatol. 2009 Dec. 21(12):1333-9. [Medline].

  15. Chalasani N, Wilcox CM. Etiology and outcome of lower gastrointestinal bleeding in patients with AIDS. Am J Gastroenterol. 1998 Feb. 93(2):175-8. [Medline].

  16. Huang ES, Strate LL, Ho WW, Lee SS, Chan AT. Long-term use of aspirin and the risk of gastrointestinal bleeding. Am J Med. 2011 May. 124(5):426-33. [Medline]. [Full Text].

  17. [Guideline] Scottish Intercollegiate Guidelines Network (SIGN). Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2008 Sep. SIGN publication; no. 105: [Full Text].

  18. Andrei GN, Popa B, Gulie L, et al. Highlighted steps of the management algorithm in acute lower gastrointestinal bleeding - case reports and literature review. Chirurgia (Bucur). 2016 Jan-Feb. 111 (1):74-9. [Medline].

  19. Cirocchi R, Grassi V, Cavaliere D, et al. New trends in acute management of colonic diverticular bleeding: a systematic review. Medicine (Baltimore). 2015 Nov. 94 (44):e1710. [Medline].

  20. Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc. 1999 Feb. 49(2):228-38. [Medline].

  21. McGuire HH Jr. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg. 1994 Nov. 220(5):653-6. [Medline]. [Full Text].

  22. [Guideline] Wilkins T, Baird C, Pearson AN, Schade RR. Diverticular bleeding. Am Fam Physician. 2009 Nov 1. 80(9):977-83. [Medline].

  23. Ryan MJ, Key SM, Dumbleton SA, MD, et al. Nonlocalized Lower Gastrointestinal Bleeding: Provocative Bleeding Studies with Intraarterial tPA, Heparin, and Tolazoline. J Vasc Interv Radiol. 2001. 12:1273-77.

  24. Macari M, Chandarana H, Balthazar E, Babb J. Intestinal ischemia versus intramural hemorrhage: CT evaluation. AJR Am J Roentgenol. 2003 Jan. 180(1):177-84. [Medline].

  25. Sabharwal R, Vladica P, Chou R, Law WP. Helical CT in the diagnosis of acute lower gastrointestinal haemorrhage. Eur J Radiol. 2006 May. 58(2):273-9. [Medline].

  26. Lee S, Welman CJ, Ramsay D. Investigation of acute lower gastrointestinal bleeding with 16- and 64-slice multidetector CT. J Med Imaging Radiat Oncol. 2009 Feb. 53(1):56-63. [Medline].

  27. Frattaroli FM, Casciani E, Spoletini D, Polettini E, Nunziale A, Bertini L, et al. Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding. World J Surg. 2009 Oct. 33(10):2209-17. [Medline].

  28. Moss AJ, Tuffaha H, Malik A. Lower GI bleeding: a review of current management, controversies and advances. Int J Colorectal Dis. 2015 Oct 10. [Medline].

  29. Wong RC. Immediate unprepared hydroflush colonoscopy for management of severe lower gastrointestinal bleeding. Gastroenterol Hepatol (N Y). 2013 Jan. 9(1):31-4. [Medline]. [Full Text].

  30. Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology. 1988 Dec. 95(6):1569-74. [Medline].

  31. Cohn SM, Moller BA, Zieg PM, Milner KA, Angood PB. Angiography for preoperative evaluation in patients with lower gastrointestinal bleeding: are the benefits worth the risks?. Arch Surg. 1998 Jan. 133(1):50-5. [Medline].

  32. Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol. 2010 Dec. 105(12):2636-41; quiz 2642. [Medline].

  33. Emslie JT, Zarnegar K, Siegel ME, Beart RW Jr. Technetium-99m-labeled red blood cell scans in the investigation of gastrointestinal bleeding. Dis Colon Rectum. 1996 Jul. 39(7):750-4. [Medline].

  34. Ng DA, Opelka FG, Beck DE, Milburn JM, Witherspoon LR, Hicks TC, et al. Predictive value of technetium Tc 99m-labeled red blood cell scintigraphy for positive angiogram in massive lower gastrointestinal hemorrhage. Dis Colon Rectum. 1997 Apr. 40(4):471-7. [Medline].

  35. Ryan P, Styles CB, Chmiel R. Identification of the site of severe colon bleeding by technetium-labeled red-cell scan. Dis Colon Rectum. 1992 Mar. 35(3):219-22. [Medline].

  36. Kester RR, Welch JP, Sziklas JP. The 99mTc-labeled RBC scan. A diagnostic method for lower gastrointestinal bleeding. Dis Colon Rectum. 1984 Jan. 27(1):47-52. [Medline].

  37. Ferrant A, Dehasque N, Leners N, Meunier H. Scintigraphy with In-111-labeled red cells in intermittent gastrointestinal bleeding. J Nucl Med. 1980 Sep. 21(9):844-5. [Medline].

  38. Schmidt KG, Rasmussen JW, Grove O, Andersen D. The use of indium-111-labelled platelets for scintigraphic localization of gastrointestinal bleeding, with special reference to occult bleeding. Scand J Gastroenterol. 1986 May. 21(4):407-14. [Medline].

  39. Mole DJ, Hughes SJ, Khosraviani K. 111Indium-labelled red-cell scintigraphy to detect intermittent gastrointestinal bleeding from synchronous small- and large-bowel adenocarcinomas. Eur J Gastroenterol Hepatol. 2004 Aug. 16(8):795-9. [Medline].

  40. Bentley DE, Richardson JD. The role of tagged red blood cell imaging in the localization of gastrointestinal bleeding. Arch Surg. 1991 Jul. 126(7):821-4. [Medline].

  41. Hunter JM, Pezim ME. Limited value of technetium 99m-labeled red cell scintigraphy in localization of lower gastrointestinal bleeding. Am J Surg. 1990 May. 159(5):504-6. [Medline].

  42. Browder W, Cerise EJ, Litwin MS. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg. 1986 Nov. 204(5):530-6. [Medline]. [Full Text].

  43. Widlus DM, Salis AI. Reteplase provocative visceral arteriography. J Clin Gastroenterol. 2007 Oct. 41(9):830-3. [Medline].

  44. Sahn B, Bitton S. Lower gastrointestinal bleeding in children. Gastrointest Endosc Clin N Am. 2016 Jan. 26 (1):75-98. [Medline].

  45. Ell C, Remke S, May A, Helou L, Henrich R, Mayer G. The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding. Endoscopy. 2002 Sep. 34(9):685-9. [Medline].

  46. Ledermann HP, Schoch E, Jost R, Decurtins M, Zollikofer CL. Superselective coil embolization in acute gastrointestinal hemorrhage: personal experience in 10 patients and review of the literature. J Vasc Interv Radiol. 1998 Sep-Oct. 9(5):753-60. [Medline].

  47. Gordon RL, Ahl KL, Kerlan RK, Wilson MW, LaBerge JM, Sandhu JS, et al. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg. 1997 Jul. 174(1):24-8. [Medline].

  48. Frodsham A, Berkmen T, Ananian C, Fung A. Initial experience using N-butyl cyanoacrylate for embolization of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2009 Oct. 20(10):1312-9. [Medline].

  49. Guy GE, Shetty PC, Sharma RP, Burke MW, Burke TH. Acute lower gastrointestinal hemorrhage: treatment by superselective embolization with polyvinyl alcohol particles. AJR Am J Roentgenol. 1992 Sep. 159(3):521-6. [Medline].

  50. Kuo WT, Lee DE, Saad WE, Patel N, Sahler LG, Waldman DL. Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2003 Dec. 14(12):1503-9. [Medline].

  51. Rossetti A, Buchs NC, Breguet R, Bucher P, Terraz S, Morel P. Transarterial embolization in acute colonic bleeding: review of 11 years of experience and long-term results. Int J Colorectal Dis. 2012 Dec 4. [Medline].

  52. Mensel B, Kühn JP, Kraft M, et al. Selective microcoil embolization of arterial gastrointestinal bleeding in the acute situation: outcome, complications, and factors affecting treatment success. Eur J Gastroenterol Hepatol. 2012 Feb. 24(2):155-63. [Medline].

  53. Yap FY, Omene BO, Patel MN, et al. Transcatheter Embolotherapy for Gastrointestinal Bleeding: A Single Center Review of Safety, Efficacy, and Clinical Outcomes. Dig Dis Sci. 2013 Jan 30. [Medline].

  54. Yata S, Ihaya T, Kaminou T, et al. Transcatheter arterial embolization of acute arterial bleeding in the upper and lower gastrointestinal tract with N-butyl-2-cyanoacrylate. J Vasc Interv Radiol. 2013 Mar. 24(3):422-31. [Medline].

  55. Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB 2nd, Healy JF. Postembolic colonic infarction. Radiology. 1982 Jan. 142(1):47-51. [Medline].

  56. Köhler G, Koch OO, Antoniou SA, et al. Relevance of surgery after embolization of gastrointestinal and abdominal hemorrhage. World J Surg. 2014 Sep. 38(9):2258-66. [Medline].

  57. Hu ML, Wu KL, Chiu KW, et al. Predictors of rebleeding after initial hemostasis with epinephrine injection in high-risk ulcers. World J Gastroenterol. 2010 Nov 21. 16(43):5490-5. [Medline]. [Full Text].

  58. Fusaroli P, Grillo A, Zanarini S, Caletti G. Usefulness of a second endoscopic arm to improve therapeutic endoscopy in the lower gastrointestinal tract. Preliminary experience - a case series. Endoscopy. 2009 Nov. 41(11):997-1000. [Medline].

  59. Hunter JG, Bowers JH, Burt RW, Sullivan JJ, Stevens SL, Dixon JA. Lasers in endoscopic gastrointestinal surgery. Am J Surg. 1984 Dec. 148(6):736-41. [Medline].

  60. Sharma P, Barajas FJ, Krishnamoorthy P, Campo LM, Blumenthal E, Spinnell M. Transfusion-free Management of Gastrointestinal Bleeding: The Experience of a Bloodless Institute. J Clin Gastroenterol. 2014 Aug 20. [Medline].

  61. Barnert J, Messmann H. Management of lower gastrointestinal tract bleeding. Best Pract Res Clin Gastroenterol. 2008. 22(2):295-312. [Medline].

  62. Cryer B, Li C, Simon LS, Singh G, Stillman MJ, Berger MF. GI-REASONS: a novel 6-month, prospective, randomized, open-label, blinded endpoint (PROBE) trial. Am J Gastroenterol. 2013 Mar. 108(3):392-400. [Medline]. [Full Text].

  63. Hammond KL, Beck DE, Hicks TC, Timmcke AE, Whitlow CW, Margolin DA. Implications of negative technetium 99m-labeled red blood cell scintigraphy in patients presenting with lower gastrointestinal bleeding. Am J Surg. 2007 Mar. 193(3):404-7; discussion 407-8. [Medline].

  64. Miller FH, Hwang CM. An initial experience: using helical CT imaging to detect obscure gastrointestinal bleeding. Clin Imaging. 2004 Jul-Aug. 28(4):245-51. [Medline].

  65. Moukarbel GV, Signorovitch JE, Pfeffer MA, McMurray JJ, White HD, Maggioni AP, et al. Gastrointestinal bleeding in high risk survivors of myocardial infarction: the VALIANT Trial. Eur Heart J. 2009 Sep. 30(18):2226-32. [Medline].

  66. Mönkemüller K, Neumann H, Meyer F, Kuhn R, Malfertheiner P, Fry LC. A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding. Endoscopy. 2009 Aug. 41(8):715-7. [Medline].

  67. Wong Kee Song LM, Baron TH. Endoscopic management of acute lower gastrointestinal bleeding. Am J Gastroenterol. 2008 Aug. 103(8):1881-7. [Medline].

  68. Zuccaro G. Epidemiology of lower gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008. 22(2):225-32. [Medline].

  69. Thomson M, Belsha D. Endoscopic management of acute gastrointestinal bleeding in children: Time for a radical rethink. J Pediatr Surg. 2015 Dec 1. [Medline].

  70. Nagata N, Niikura R, Yamada A, et al. Acute middle gastrointestinal bleeding risk associated with NSAIDs, antithrombotic drugs, and PPIs: a multicenter case-control study. PLoS One. 2016. 11 (3):e0151332. [Medline].

 
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Types of lower gastrointestinal bleeding (LGIB).
Methods used to treat lower gastrointestinal bleeding (LGIB).
Types of lower gastrointestinal (GI) bleeding. HR = heart rate; SBP = systolic blood pressure.
Algorithm for massive lower gastrointestinal (GI) bleeding, surgical perspective. EGD = esophagogastroduodenoscopy; NG = nasogastric; 99mTc RBC = technetium-99m pertechnetate–labeled autologous RBC.
Table 1. Common Causes of Lower Gastrointestinal Bleeding in Adults
Lower Gastrointestinal Bleeding in Adults Percentage of Patients
Diverticular disease
  • Diverticulosis/diverticulitis of small intestine
  • Diverticulosis/diverticulitis of colon
60%
Inflammatory bowel disease
  • Crohn disease of small bowel, colon, or both
  • Ulcerative colitis
  • Noninfectious gastroenteritis and colitis
13%
Benign anorectal diseases
  • Hemorrhoids
  • Anal fissure
  • Fistula-in-ano
11%
Neoplasia
  • Malignant neoplasia of small intestine
  • Malignant neoplasia of colon, rectum, and anus
9%
Coagulopathy 4%
Arteriovenous malformations (AVMs) 3%
TOTAL 100%
Source: Vernava AM, Longo WE, Virgo KS. A nationwide study of the incidence and etiology of lower gastrointestinal bleeding. Surg Res Commun. 1996;18:113-20.[9]
Table 2. Common Causes of Lower Gastrointestinal Bleeding in Children and Adolescents
Lower Gastrointestinal Bleeding in Children and Adolescents
Intussusception
Polyps and polyposis syndromes
  • Juvenile polyps and polyposis
  • Peutz-Jeghers syndrome
  • Familial adenomatous polyposis (FAP)
Inflammatory
  • Crohn disease
  • Ulcerative colitis
  • Indeterminate colitis
Meckel diverticulum
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