eMedicine Specialties > General Surgery > Colorectal
Lower Gastrointestinal Bleeding, Surgical Treatment
Updated: Oct 29, 2009
Introduction
Acute lower gastrointestinal (GI) hemorrhage accounts for approximately 20% of all cases of GI hemorrhage. The annual incidence is about 20-27 cases per 100,000 population in westernized countries. Lower GI hemorrhage continues to be a frequent cause of hospital admission and is a factor in hospital morbidity and mortality. Mortality rates are reportedly 10-20% and are dependent on age (>60 y), multiorgan system disease, transfusion requirements in excess of 5 units, need for operation, and recent stress (eg, surgery, trauma, sepsis).
Localization of hemorrhage relative to the Treitz ligamentum directs the initial evaluation and resuscitation. The passage of maroon stools or bright red blood from the rectum is usually indicative of massive lower GI hemorrhage. Lower GI hemorrhage can be due to numerous conditions, including diverticulosis, anorectal diseases, carcinomas, inflammatory bowel disease (IBD), and angiodysplasias. (See images below and Images 1-2.)
For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Gastrointestinal Bleeding, Rectal Bleeding, Inflammatory Bowel Disease, Diverticulosis and Diverticulitis, and Anal Abscess.
Types of lower gastrointestinal (GI) bleeding.
Algorithm for massive lower gastrointestinal (GI) bleeding.
History of the Procedure
Understanding of the pathogenesis, diagnosis, and treatment of lower GI bleeding has drastically changed during the last 50 years. In the first half of the 20th century, large intestinal neoplasms were believed to be the most common cause of lower GI bleeding. In the 1950s, lower GI hemorrhage was commonly attributed to diverticulosis. In this period, surgical treatment consisted of blind segmental bowel resections, with disappointing results. Patients who underwent blind segmental bowel resection suffered from a prohibitively high rebleeding rate (up to 75%), morbidity (up to 83%), and mortality (up to 60%).
In the last 4 decades, diagnostic methods for locating the precise bleeding point greatly improved. In 1965, Baum et al described selective mesenteric angiography, which permitted the identification of vascular abnormalities and the precise bleeding point.1 Experience with mesenteric angiography in the late 1960s and 1970s suggested that angiodysplasias and diverticulosis were the most common reasons for lower GI bleeding. Since its discovery, mesenteric angiography remains the criterion standard in precise localization of the bleeding.
Rösch et al described superselective visceral arteriography for infusion of vasoconstrictors in 1971 and superselective embolization of the mesenteric vessels as an alternative technique to treat massive lower GI bleeding in 1972.2 The most feared complication of embolization of the mesenteric vessels is ischemic colitis, which has limited its use for GI bleeding.
The initial experience with vasopressin infusion was reported in 1973-1974. Vasopressin causes vasoconstriction and arrests the bleeding in 36-100% of patients. The recurrence rate following completion of vasopressin infusion can be as high as 71%; therefore, vasopressin is used to temporize the acute event and to stabilize patients before surgery.
The flexible endoscope was developed in 1954. The full-length colonoscope was developed in 1965 in Japan. The first anal colonoscopy was performed in 1969. Endoscopic control of bleeding with thermal modalities or sclerosing agents has been in use since the 1980s. One of the advantages of upper (or lower) endoscopic evaluation is that it provides a means to administer therapy in patients with GI bleeding. Nuclear scintigraphy has been used since the early 1980s as a very sensitive diagnostic tool to evaluate bleeding from GI tract. Nuclear scintigraphy can detect hemorrhage at rates as low as 0.1 mL/min.
The average age of patients with lower GI bleeding is 60 years in most series. Etiology varies according to the age of the patient. Segmental bowel resection following precise localization of the bleeding point is a well-accepted surgical practice today. Despite improvement in diagnostic imaging and procedures, 10-20% of patients with lower GI bleeding have no demonstrable bleeding source. Subtotal colectomy is the procedure of choice in patients who are actively bleeding from an unknown source.
Problem
Lower GI hemorrhage is defined as an abnormal intraluminal blood loss from a source distal to the Treitz ligamentum. Lower GI bleeding is classified under 3 groups according to the amount of bleeding (see image below and Image 1). Massive hemorrhage is a life-threatening condition and requires transfusion of at least 5 units of blood.
Types of lower gastrointestinal (GI) bleeding.
Patients with massive hemorrhage present with a systolic blood pressure of less than 90 mm Hg and a hemoglobin 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. Therefore, the overall mortality rate for massive lower GI hemorrhage ranges from 0-21%. Occult bleeding manifests as microcytic hypochromic anemia and intermittent guaiac reaction (see Image 1).
- Definition of massive lower GI bleeding
- Passage of a large volume of red or maroon blood through the rectum
- Hemodynamic instability and shock
- Initial decrease in hematocrit (Hct) level of 6 g/dL or less
- Transfusion of at least 2 units of packed RBCs
- Bleeding that continues for 3 days
- Significant rebleeding in 1 week
Frequency
The total incidence of lower GI bleeding in the United States is not known; although lower GI bleeding is common, most patients do not require hospitalization.
Vernava et al reviewed Department of Veterans Affairs' (VA) databases for a 4-year period to study the incidence and etiology of lower GI bleeding. They found that less than 1% of 5.1 million hospital admissions were for lower GI hemorrhage. Another study, in which the Kaiser Permanente database was reviewed, estimated an annual incidence rate of 20.5 patients per 100,000 (24.2 in males vs 17.2 in females). The rate of lower GI bleeding increased more than 200-fold from the third to the ninth decades of life.
Etiology
Bleeding from diverticular disease has been reported as the most common reason for massive lower GI bleeding in most of the single-institution publications. However, the reported frequency of various other etiologies of lower GI bleeding is not consistent in these manuscripts because of the small number of cases and the highly selective referral pattern and patient populations. Comprehensive knowledge of the etiology of lower GI bleeding is essential for patient management and, ultimately, for patient outcome.
In a retrospective review of medical records from approximately 1100 patients with acute lower GI bleeding, all of whom were admitted to the surgical service of a single urban emergency hospital, Gayer et al determined that the most common etiologies for bleeding in these patients were diverticulosis (33.5%), hemorrhoids (22.5%), and carcinoma (12.7%).3 The investigators also found that most patients in the study (55.5%) presented with hematochezia, with the next most frequent presentations being maroon stools (16.7%) and melena (11%).
Vernava and colleagues' review found that patients with lower GI bleeding made up only 0.7% of all hospital admissions (17,941 patients). The average age of these patients was 64 years. Only 24% of these patients (4410) had a diagnostic workup, including colonoscopy, barium enema, and/or mesenteric angiography. Among the patients who underwent a diagnostic workup, the most common causes of bleeding were diverticular disease (60%), IBD (13%), and anorectal diseases (11%) (see Table 1), the figures differing somewhat from the above-mentioned study by Gayer et al. Although some publications have reported arteriovenous malformations as a common cause of lower GI bleeding, the true incidence of arteriovenous malformations is insignificant (3%), as stated by Vernava et al.
Table 1: Common Causes of Lower GI Bleeding in Adults*
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Table
| LOWER GI HEMORRHAGE IN ADULTS | PERCENTAGE OF PATIENTS |
| Diverticular disease -Diverticulosis/diverticulitis of small intestine -Diverticulosis/diverticulitis of colon | 60% |
| IBD -Crohn's 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 (AVM) | 3% |
| TOTAL | 100% |
| LOWER GI HEMORRHAGE IN ADULTS | PERCENTAGE OF PATIENTS |
| Diverticular disease -Diverticulosis/diverticulitis of small intestine -Diverticulosis/diverticulitis of colon | 60% |
| IBD -Crohn's 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 (AVM) | 3% |
| TOTAL | 100% |
*From Vernava and colleagues' survey of 4410 patients
Longstreth reviewed the discharge summary and colonoscopy data from a large health maintenance organization with members in the San Diego, Calif, area. In all, 235 hospital admissions for 219 patients were reviewed. The estimated hospital admission rate for lower GI bleeding was found to be 20 patients per 100,000 admissions. Bleeding from diverticular disease was the most common reason for lower GI bleeding (42%), followed by colorectal malignancies (9%) and ischemic colitis (8.7%). The incidence of lower GI bleeding due to colonic angiodysplasias was 6%. These findings were consistent with those of the VA database study, although that study was limited to males.
The common causes of lower GI bleeding in infants, children, and adolescents differ from those found in adults. Meckel diverticulum, intussusception, polyposis syndromes, and IBD are the common causes of GI bleeding in children and adolescents (see Table 2).4
Table 2: Common Causes of Lower GI Hemorrhage in Children and Adolescents
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Table
| LOWER GI HEMORRHAGE IN CHILDREN & ADOLESCENTS |
| Intussusception |
| Polyps and polyposis syndromes -Juvenile polyps and polyposis -Peutz-Jeghers syndrome -Familial adenomatous polyposis (FAP) |
| IBD -Crohn's disease -Ulcerative colitis -Indeterminate colitis |
| Meckel diverticulum |
| LOWER GI HEMORRHAGE IN CHILDREN & ADOLESCENTS |
| Intussusception |
| Polyps and polyposis syndromes -Juvenile polyps and polyposis -Peutz-Jeghers syndrome -Familial adenomatous polyposis (FAP) |
| IBD -Crohn's disease -Ulcerative colitis -Indeterminate colitis |
| Meckel diverticulum |
Many other causes of lower GI bleeding have been documented, including hemorrhage from small bowel diverticulosis, Dieulafoy lesions of the colon or small bowel, portal colopathy with colonic and rectal varices, endometriosis, solitary rectal ulcer syndrome, and vasculitides with small bowel or colonic ulcerations (see Rare causes of lower GI bleeding).
Pathophysiology
Diverticulosis is a common acquired condition in Western societies. Approximately 50% of adults older than 60 years have radiologic evidence of diverticulosis. Diverticula are most commonly located in the sigmoid and descending colon. Diverticular bleeding originates from vasa rectae located in submucosa, which can rupture at the dome or the neck of the diverticulum. Up to 20% of patients with diverticular disease experience bleeding. In 5% of patients, bleeding from diverticular disease can be massive. Hemorrhage from diverticular disease stops spontaneously in 80% of patients. Although diverticulosis is a left colonic condition, approximately 50% of diverticular bleeding originates from a diverticulum located proximal to the splenic flexure. Diverticula located on the right side may expose the larger portions of vasa rectae to injury because they have wider necks and larger domes compared to the typical left-sided colonic diverticulum.
Colonic angiodysplasias are arteriovenous malformations located in the cecum and ascending colon. Colonic angiodysplasias are an acquired lesion affecting elderly persons older than 60 years. These lesions are composed of clusters of dilated vessels, mostly veins, in the colonic mucosa and submucosa. Colonic angiodysplasias are believed to occur as a result of chronic, intermittent, low-grade obstruction of submucosal veins as they penetrate the muscular layer of the colon. The characteristic angiographic findings are clusters of small arteries during the arterial phase of the study, accumulation of contrast media in vascular tufts, early opacification, and persistent opacification due to the late emptying of the draining veins. If mesenteric angiography is performed at the time of active bleeding, extravasation of contrast media is visualized.
Unlike diverticular bleeding, angiodysplasia tends to cause slow but repeated episodes of bleeding. Therefore, patients with angiodysplasia present with anemia and syncopal episodes. Infrequently, angiodysplasias can cause an abrupt loss of large quantities of blood. Angiodysplasias can be easily recognized by colonoscopy as 1.5- to 2-mm red patches in the mucosa. Actively bleeding lesions can be treated with colonoscopic electrocoagulation. Incidentally discovered lesions should be left alone.
Massive hemorrhage due to IBD is rare. Ulcerative colitis causes bloody diarrhea in most cases. In up to 50% of patients with ulcerative colitis, mild-to-moderate lower GI bleeding occurs, and approximately 4% of patients with ulcerative colitis have massive hemorrhage.
Lower GI bleeding in patients with Crohn’s disease is not as common as in patients with ulcerative colitis; 1-2% of patients with Crohn’s disease may experience massive bleeding. The frequency of bleeding in patients with Crohn’s disease is significantly more common with colonic involvement than with small bowel involvement alone.
Ischemic colitis, the most common form of ischemic injury to the digestive system, frequently involves the watershed areas, including the splenic flexure and the rectosigmoid junction. In most cases, the precipitating event cannot be identified. Colonic ischemia is a disease of the elderly population and is commonly observed after patients' sixth decade of life. Ischemia causes mucosal and partial-thickness colonic wall sloughing, edema, and bleeding. Ischemic colitis is not associated with significant blood loss or hematochezia, although abdominal pain and bloody diarrhea are the main clinical manifestations.
Colorectal adenocarcinoma is the third most common cancer in the United States. Colorectal carcinoma causes occult bleeding, and patients usually present with anemia and syncopal episode. The incidence of massive bleeding due to colorectal carcinoma varies from 5-20% in different series. Postpolypectomy hemorrhage is reported to occur up to 1 month following colonoscopic resection. The reported incidence is between 0.2-3%. Postpolypectomy hemorrhage can be managed by electrocoagulation of the polypectomy site/bleeding with either snare or hot biopsy forceps or by epinephrine injection.
Benign anorectal disease (eg, hemorrhoids, anal fissures, anorectal fistulas) can cause intermittent rectal bleeding. Massive rectal bleeding due to benign anorectal disease has also been reported. The VA database review revealed that 11% of patients with lower GI bleeding had hemorrhage from anorectal disease. Patients who have rectal varices with portal hypertension may develop painless massive lower GI bleeding; 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.Presentation
Massive lower GI bleeding is a life-threatening condition. Although massive lower GI bleeding manifests as maroon stools or bright red blood from the rectum, patients with massive upper GI bleeding may also present with similar findings. Regardless of the level of the bleeding, one of the most important elements of the management of patients with massive upper or lower GI bleeding is the initial resuscitation. These patients should receive 2 large-bore intravenous catheters and isotonic crystalloid infusions. Meanwhile, rapid assessment of vital signs, including heart rate, systolic blood pressure, pulse pressure, and urine output, should be performed. Orthostatic hypotension (ie, a blood pressure fall of >10 mm Hg) is usually indicative of blood loss of more than 1000 mL.
History and physical examination are essential parts of an initial evaluation. Document prior episodes of GI bleeding as well as significant medical history and prior medications, including peptic ulcer disease, liver disease, cirrhosis, coagulopathy, IBDs, and use of nonsteroidal anti-inflammatory drugs (NSAIDs) and/or warfarin. Symptoms are also important in identifying the source of bleeding. The symptoms of young patients with abdominal pain, rectal bleeding, diarrhea, and mucous discharge may be associated with IBD. On the other hand, symptoms of elderly patients with abdominal pain, rectal bleeding, and diarrhea can be associated with ischemic colitis. 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.
The physical examination must include careful inspection and examination of the oropharynx, nasopharynx, abdomen, perineum, and anal canal. Nasogastric aspirates usually correlate well with upper gastric hemorrhage proximal to the Treitz ligamentum; therefore, insert a nasogastric 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 from the nasogastric tube to exclude any upper GI bleeding beyond the pylorus.
Nasogastric tube aspirates can provide false-negative results in approximately 50% of cases if the aspirate contains no bile or if the bleeding is intermittent. These patients eventually need esophagogastroduodenoscopy (EGD) 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.Indications
Surgical treatment is indicated if the patient continues to bleed and if nonoperative management is unsuccessful or unavailable. Segmental colectomy is indicated if the bleeding point is localized by preoperative diagnostic studies. Subtotal colectomy is the procedure of choice if the bleeding point cannot be localized with preoperative or intraoperative diagnostic studies. Subtotal colectomy is associated with negligibly higher perioperative morbidity and mortality compared to segmental colonic resection. In addition, postoperative diarrhea can be a significant problem in elderly patients who undergo subtotal colectomy and ileorectal anastomosis.
Relevant Anatomy
The average length of the large intestine is 135-150 cm. Ascending and descending segments of the colon are fixed to the retroperitoneum. On the other hand, the transverse and sigmoid colon are supported by a mesentery in the abdomen. A comprehensive understanding of small bowel and colonic vascular anatomy is essential for any surgeon performing primary lower GI surgery for hemorrhage or other diseases.
The ileocolic, right colic, and middle colic branches of the superior mesenteric artery supply blood to the cecum, ascending, and proximal transverse colon, respectively. The superior mesenteric vein drains the right side of the colon, joining the splenic vein to form the portal vein. The inferior mesenteric artery supplies blood to the distal transverse, descending, and sigmoid colon. The inferior mesenteric vein carries blood from the left side of the colon to the splenic vein. A rich network of vessels from the superior, middle, and inferior hemorrhoidal vessels supplies the rectosigmoid junction and rectum.
Contraindications
No contraindications exist with regard to surgery in hemodynamically unstable patients with active bleeding. Surgery is warranted even in the absence of accurate preoperative localization for patients who require transfusion of 5 units or more blood in the first 24 hours. Surgery is also necessary in patients with recurrent bleeding during the same hospitalization.
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Further Reading
Clinical guidelines:
ACR Appropriateness Criteria® left lower quadrant pain. American College of Radiology - Medical Specialty Society. 1996 (revised 2008). 5 pages. NGC:006988
ACR Appropriateness Criteria® treatment of acute nonvariceal gastrointestinal tract bleeding. American College of Radiology - Medical Specialty Society. 2006. 6 pages. NGC:005537
ASGE guideline: the role of endoscopy in the patient with lower-GI bleeding. American Society for Gastrointestinal Endoscopy - Medical Specialty Society. 2005 Nov. 5 pages. NGC:004584
Practice parameters for the management of hemorrhoids (revised). American Society of Colon and Rectal Surgeons - Medical Specialty Society. 1993 (revised 2005 Feb). 6 pages. NGC:004337
Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). American Society of Colon and Rectal Surgeons - Medical Specialty Society. 1996 (revised 2005 Jul). 6 pages. NGC:004432
Clinical trials:
A Study To Investigate The Safety And Efficacy Of CP- 690,550 In Patients With Moderate And Severe Ulcerative Colitis.
Mechanistic Randomized Controlled Trial (RCT) of Mesalazine in Symptomatic Diverticular Disease
Keywords
lower gastrointestinal bleeding, gastrointestinal bleeding, rectal bleeding, colectomy, gastrointestinal endoscopy, gastrointestinal bleed, lower GI bleeding, rectal hemorrhage, lower diverticular hemorrhage, diverticular bleeding, diverticulosis, anorectal diseases, inflammatory bowel disease, IBD, angiodysplasias, small bowel diverticulosis
