eMedicine Specialties > Radiology > Vascular/Interventional

Gastrointestinal Bleeding, Lower

Author: Atif Rana, MBBS, Assistant Professor, Department of Radiology, Shifa College of Medicine, Islamabad, Pakistan
Contributor Information and Disclosures

Updated: Apr 13, 2009

Introduction

Background

Lower gastrointestinal (GI) hemorrhage is defined as bleeding from the bowel distal to the ligament of Treitz. Acute lower GI bleeding is of recent onset and results in hemodynamic instability and decreasing hemoglobin levels, which need to be treated with transfusions.

Lower gastrointestinal bleeding. Technetium-99m R...

Lower gastrointestinal bleeding. Technetium-99m RBC scan shows an abnormal focus of increasing activity in the right lower quadrant, consistent with gastrointestinal bleeding. This activity is seen to increase in intensity over time. The patient underwent angiography (see Images below).

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Lower gastrointestinal bleeding. Technetium-99m R...

Lower gastrointestinal bleeding. Technetium-99m RBC scan shows an abnormal focus of increasing activity in the right lower quadrant, consistent with gastrointestinal bleeding. This activity is seen to increase in intensity over time. The patient underwent angiography (see Images below).


Lower gastrointestinal bleeding. Superior mesente...

Lower gastrointestinal bleeding. Superior mesenteric arterial arteriogram shows extravasation of contrast material from the right colic branch.

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Lower gastrointestinal bleeding. Superior mesente...

Lower gastrointestinal bleeding. Superior mesenteric arterial arteriogram shows extravasation of contrast material from the right colic branch.


Lower gastrointestinal bleeding. Selective arteri...

Lower gastrointestinal bleeding. Selective arteriogram through a microcatheter further localizes the point of bleeding (same patient as in Images above).

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Lower gastrointestinal bleeding. Selective arteri...

Lower gastrointestinal bleeding. Selective arteriogram through a microcatheter further localizes the point of bleeding (same patient as in Images above).


Colonoscopy has emerged as the procedure of choice, but angiography still remains the best option in a patient in unstable condition. In cases in which colonoscopy is unsuccessful, scanning during episodes of bleeding and arteriography are considered to be next imaging tests to determine the cause of the bleeding. Arteriography also provides therapeutic options. This article reviews the current recommendations for work-up and management of acute lower GI bleeds.

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Gastrointestinal Bleeding and Rectal Bleeding.

Pathophysiology

The causes of acute lower GI bleeding include diverticulosis,1  angiodysplasia, colon cancer, colitis (including infectious, ischemic, or radiation-induced forms), inflammatory bowel disease, polyps, Meckel diverticulum,2 and aortoenteric fistula. Hemorrhoids are probably the most common cause of lower GI bleeding, but they usually do not pose difficulties in the diagnosis and they rarely cause massive bleeding. Similarly, anorectal fissures can bleed, but again, these are easily diagnosed on the basis of the history and the clinical findings.

Lower GI bleeding appears as the passage of bright red blood per rectum. In about 10-15% of cases, the cause may be proximal to the ligament of Treitz. In these cases, nasogastric tube placement is frequently needed to confirm that the upper GI tract is the source of the bleeding.

The most common cause of lower GI bleeding involves the colonic diverticula. In 1976, Myeres et al reported on the pathogenesis of bleeding diverticula. They showed asymmetric rupture of the vasa recta at the dome of the diverticulum, with intimal eccentric thickening and medial thinning at or near the bleeding point. Comparing this with control diverticula, they suggested that traumatic injury may play a role in predisposing the diverticula to bleeding and rupture. Diverticulosis has been implicated as the source of bleeding in as many as 60% of cases of lower GI bleeding. The diverticula are more prevalent in the left or sigmoid colon, but positive arteriographic findings for bleeding localizes the bleeding to the right colon in 60% of cases.

Angiodysplasia has an incidence of 1-2%; this involves ectatic vessels in the mucosa and submucosa of the GI tract. At endoscopy, they appear as red, flat lesions, and a feeding vessel is sometimes shown. These vessels are reported to be responsible for 3-12% of cases of acute lower GI bleeding. The majority are present in the right colon. An association with various systemic diseases has been described; these diseases include aortic stenosis, von Willebrand disease, chronic obstructive pulmonary disease (COPD), cirrhosis, chronic renal disease, and collagen vascular disease.

Other causes of lower GI bleeding include neoplasia, such as a polyp or carcinoma. Significant bleeding can also occur in about 2-4% of cases after endoscopic removal of polyps from the colon, though other studies have shown lower rates. Inflammatory bowel disease and other types of colitis account for as many as 30% of cases of acute lower intestinal bleeding. Less frequent causes of acute colorectal bleeding include solitary rectal ulcer,3 portal colopathy, Dieulafoy lesions of the colon, endometriosis, and colonic varices.

More on Gastrointestinal Bleeding, Lower

Overview: Gastrointestinal Bleeding, Lower
Imaging: Gastrointestinal Bleeding, Lower
Follow-up: Gastrointestinal Bleeding, Lower
Multimedia: Gastrointestinal Bleeding, Lower
References
Further Reading
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References

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Further Reading

Clinical guidelines
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

Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.].  2008 Sep.  57 pages.  NGC:006730

Clinical trials

 Diagnostic Evaluation of Obscure Gastrointestinal Bleeding

Related eMedicine topics

 Lower Gastrointestinal Bleeding (gastroenterology)

Lower Gastrointestinal Bleeding: Surgical Perspective

Diverticular Disease (emergency medicine)

Pediatrics, Gastrointestinal Bleeding

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Keywords

lower gastrointestinal bleeding, GI bleeding, lower GI bleeding, gastrointestinal hemorrhage, GI hemorrhage

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Contributor Information and Disclosures

Author

Atif Rana, MBBS, Assistant Professor, Department of Radiology, Shifa College of Medicine, Islamabad, Pakistan
Atif Rana, MBBS is a member of the following medical societies: Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Anthony Watkinson, MD, Professor of Interventional Radiology, The Peninsula Medical School; Consultant and Senior Lecturer, Department of Radiology, The Royal Devon and Exeter Hospital, UK
Anthony Watkinson, MD is a member of the following medical societies: Radiological Society of North America, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Douglas M Coldwell, MD, PhD,, Principal, Coldwell Associates. Interventional Radiologist, Jane Phillips Medical Center, Bartlesville, OK
Douglas M Coldwell, MD, PhD, is a member of the following medical societies: American Association for Cancer Research, American College of Radiology, American Heart Association, American Physical Society, American Roentgen Ray Society, Society of Cardiovascular and Interventional Radiology, Southwest Oncology Group, and Special Operations Medical Association
Disclosure: Sirtex, Inc. Consulting fee Speaking and teaching

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Kyung J Cho, MD, FACR, William Martel Professor of Radiology, Interventional Radiology Fellowship Director, University of Michigan Health System
Kyung J Cho, MD, FACR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

 
 
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