Diagnostic Considerations

The average age of patients with lower gastrointestinal bleeding (LGIB) is 60 years in most case 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 identification of the bleeding site. These patients often 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.

Differential diagnosis

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

Chronic radiation enteritis/proctitis
Ischemic colitis/mesenteric vascular insufficiency
Colonic/rectal varices
Portal colopathy
Solitary rectal ulcer syndrome
Diversion colitis
Vasculitides
Small bowel ulceration
GI bleeding in runners

Differential Diagnoses

Workup

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Media Gallery

Types of lower gastrointestinal bleeding (LGIB).
Methods used to treat lower gastrointestinal (GI) bleeding. CBC = complete blood cell count, coags = coagulation studies, EGD = esophagogastroduodenoscopy, NG = nasogastric, RBC = red blood cell, TRBC = tagged RBC, UGIB = upper GI bleeding.
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.

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Author

Burt Cagir, MD, FACS Associate Regional Dean and Professor of Surgery, Geisinger Commonwealth School of Medicine; Director, General Surgery Residency Program, Executive Director, Donald Guthrie Foundation for Research and Education, Guthrie Robert Packer Hospital; Medical Director, Guthrie/RPH Skills and Simulation Lab; Associate in Surgery, Guthrie Robert Packer Hospital and Corning Hospital

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

Disclosure: Nothing to disclose.

Coauthor(s)

Gabriel O Ologun, MD Resident Physician, Department of Surgery, Guthrie Robert Packer Hospital

Disclosure: Nothing to disclose.

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, American Society of Colon and Rectal 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, 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 Senior Associate Dean for Medicine and Research, Professor of Surgery, Pathology, and Biomedical Sciences, 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, The Scientific Research Honor Society

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.

Lower Gastrointestinal Bleeding in Adults	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.^[13]

Lower Gastrointestinal Bleeding Differential Diagnoses

Diagnostic Considerations

Differential diagnosis

Differential Diagnoses

References

Tables

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