Lower Gastrointestinal Bleeding Differential Diagnoses

  • Author: Burt Cagir, MD, FACS; Chief Editor: Julian Katz, MD   more...
 
Updated: Jun 1, 2011
 
 

Diagnostic Considerations

The average age of patients with lower gastrointestinal bleeding (LGIB) is 60 years in most series. Despite improvement in diagnostic imaging and procedures, 10-20% of patients with LGBI have no demonstrable bleeding source, and 5-10% of patients may present with recurrent episodes of massive LGIB without any diagnosis of the bleeding site. These patients experience multiple hospital admissions; they also undergo recurrent blood transfusions and several invasive studies repeatedly. Therefore, this complex problem requires systematic and orderly evaluation to reduce the percentage of undiagnosed and untreated cases of LGIB.

Differentials

For common conditions that cause LGIB, see Etiology. Rare causes of lower GI bleeding that may need to be considered include the following:

  • Chronic radiation enteritis/proctitis
  • Ischemic colitis/mesenteric vascular insufficiency
  • Small bowel diverticulosis
  • Meckel diverticulum
  • Colonic/rectal varices
  • Portal colopathy
  • Solitary rectal ulcer syndrome
  • Diversion colitis
  • Dieulafoy lesion of colon
  • Dieulafoy lesion of small bowel
  • Vasculitides
  • Small bowel ulceration
  • Intussusception
  • Endometriosis
  • GI bleeding in runners
Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Burt Cagir, MD, FACS  Assistant Professor of Surgery, State University of New York Upstate Medical University; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic

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

Disclosure: Nothing to disclose.

Coauthor(s)

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

Disclosure: Nothing to disclose.

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 and American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

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.

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 and American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

David Greenwald, MD  Associate 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, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Marc D Basson, MD, PhD, MBA, FACS  Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine

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, and Sigma Xi

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

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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%
Coagulopathy4%
Arteriovenous malformations (AVMs)3%
TOTAL100%
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.[6]
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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