II. Causes: Adults with Acute Massive Rectal Bleeding

  1. Diverticular Bleeding (10-20%)
    1. Painless bleeding
    2. Increased risk with NSAIDs or Aspirin
    3. Bleeding spontaneously ceases in 75%, recurs in 38%
    4. Recurrence is 9% at one year and 25% at 4 years
  2. Angiodysplasia (3-12%)
    1. Recurrent painless bleeding
  3. Colon Cancer (2-26%)
    1. Slow chronic blood loss with change in bowel habits
  4. Inflammatory Bowel Disease (10%)
    1. Blood Diarrhea with recurrent Abdominal Pain and weight loss
  5. Ischemic Colitis
    1. Self-limited bloody Diarrhea, followed by acute lower Abdominal Pain
    2. Seen in vascular disease patients
    3. May be foretold by prior hypotensive event
  6. Rectal ulcer (hard stool induced Pressure Ulcers)
  7. Acute infectious colitis
  8. Pseudomembranous colitis (or other Infectious Diarrhea or dysentary)
    1. Bloody Diarrhea with fever and risk factors (recent antibiotics, suspect oral intakes)
  9. Radiation Colitis
    1. May be delayed 3 years after Radiation Therapy
  10. Post-polypectomy bleeding
    1. Associated with restarting NSAID or Aspirin too soon
    2. Self-limited bleeding, usually follows polypectomy or other bowel procedure within 30 days
  11. Aortoenteric fistula (Aortic graft-enteric fistula)
    1. Occurs in those with aortic surgery history
    2. Requires immediate emergency management
  12. Internal Hemorrhoid (<10%)
  13. Consider Upper Gastrointestinal Bleeding source

III. Causes: Adults with chronic intermittent GI Bleeding

  1. Hemorrhoids (Up to 59%)
  2. Colorectal polyps (38 to 52%)
  3. Diverticulosis (34 to 51%)
  4. Colorectal Cancer (up to 8%)
  5. Ulcerative Colitis
  6. Arteriovenous malformations
  7. Colonic stricture

IV. Causes: Adults - most commonly missed lower GI sources

  1. Arteriovenous malformations
  2. Neoplasms in colon

V. Causes: Children

VI. Signs

  1. Hematochezia (bright red blood in stool)
    1. Upper Gastrointestinal Bleeding source in 5-11% of patients
  2. Nasogastric aspirate clear except for bile
    1. Positive in Upper Gastrointestinal Bleeding
  3. Normal Renal Function tests (BUN to Creatinine ratio normal)
    1. Contrast with Upper Gastrointestinal Bleeding where BUN to Creatinine ratio is increased >33
  4. Normal Bowel Sounds
  5. Hemodynamic status more stable than in Upper GI Bleed
    1. Orthostasis seen in one third of patients

VII. Labs

  1. Serum electrolytes
    1. BUN to Creatinine ratio >33 suggests Upper Gastrointestinal Bleeding source
  2. Complete Blood Count
    1. Hemoglobin or Hematocrit decreased in 50% of patients
      1. Usually less depressed than in Upper Gastrointestinal Bleeding
  3. Coaulation Studies
    1. Partial Thromboplastin Time (PTT)
    2. Prothrombin Time (PT/INR)
  4. Preparation for Blood Transfusion
    1. Consent for Blood Products
    2. Type and Crossmatch for Packed Red Blood Cells (pRBC)
  5. Assessment of comorbidity and secondary complications
    1. Electrocardiogram (EKG)
    2. Troponin

VIII. Management: Acute Gastrointestinal Bleeding

  1. Precaution
    1. Brisk persistent bleeding occurs in up to 19% of cases
  2. Initial Stabilization
    1. ABC Management
    2. Oxygen Supplementation
    3. Obtain two large bore peripheral IVs (14-16 gauge)
    4. Telemetry monitoring with Heart Rate, Oxygen Saturation and Blood Pressure monitoring (also obtain orthostatic BP and Pulse if able)
    5. Obtain acute labs as above
    6. May stabilize with crystalloid (e.g. Normal Saline) as needed for hemodynamic instability while Blood Products pending
      1. However, blood is far preferred as soon as it is available
      2. Avoid excessive crystalloid prior to transfusion
    7. Transfuse Packed Red Blood Cells for severe Anemia, symptomatic Anemia or continued heavy bleeding
    8. Consider Fresh Frozen Plasma (ffp) and platelets as indicated for Coagulopathy
  3. Avoid tests without adequate yield in acute bleeding
    1. Avoid Flexible Sigmoidoscopy
    2. Avoid Barium Enema
  4. Consider Upper Gastrointestinal Bleeding source
    1. Upper GI Bleed with Hematochezia is always unstable
    2. BUN to Creatinine ratio increased in Upper Gastrointestinal Bleeding
    3. Check Nasogastric aspirate
      1. Will show bile without blood in lower GI source
      2. Duodenal source of Upper GI Bleed may be missed
  5. Bleeding ceases spontaneously (occurs in 50% of cases)
    1. See Colonoscopy in GI Bleeding
    2. Evaluation may proceed outpatient in stable patient
    3. Colonoscopy negative: Consider Upper GI Bleed
  6. Brisk GI Bleeding obscures source on Colonoscopy
    1. See Angiography in GI Bleeding (preferred)
      1. Test of choice in massive Lower GI Bleeding
      2. May direct exploratory laparotomy
      3. Consider Arteriography with embolization or vasopressin
    2. See Radionuclide Red Cell Scan (less accurate)
      1. More useful in slower bleeding (<0.4 ml/minute)
      2. Immediate blush identifies high risk bleeding
        1. Ng (1997) Dis Colon Rectum 40:471-7 [PubMed]
  7. Slow continuous or recurrent bleeding
    1. See Colonoscopy in GI Bleeding
    2. No source on Colonoscopy
      1. Radionuclide Red Cell Scan: Positive
        1. See Angiography in GI Bleeding
        2. Consider repeat Colonoscopy in GI Bleeding
          1. Guided by red cell scan results
        3. Consider exploratory laparotomy
          1. See below for indications
      2. Radionuclide Red Cell Scan: Negative
        1. Consider Upper Endoscopy
          1. Evaluate for Hematochezia due to Upper GI Bleed
          2. These cases are always hemodynamically unstable
        2. Consider Small Intestinal Bleeding
  8. Exploratory laparotomy
    1. Adjunctive intraoperative measures
      1. Intraoperative Colonoscopy
      2. Intraoperative angiography
      3. Subtotal colectomy is a a procedure of last resort
        1. Indicated only in uncontrolled Massive Hemorrhage where no alternative management exists
        2. High morbidity and mortality associated with emergent subtotal colectomy
    2. Indications
      1. Transfusion >4 units in 24 hours
      2. Transfusion >10 units total
      3. Recurrent bleeding episodes
      4. Comorbid conditions significantly affected

IX. Management: Asymptomatic mild Rectal Bleeding (clinic)

  1. Age over 35 years: Colonoscopy
  2. Age 25 to 35 years: Diagnostics based on risk factors
  3. Age under 25 years: Anoscopy, Flexible Sigmoidoscopy
  4. Lewis (2002) Ann Intern Med 136:99-110 [PubMed]

X. Prognosis

  1. Overall mortality <5%
  2. Mortality may approach 20% if admitted for comorbidity

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Ontology: Lower gastrointestinal hemorrhage (C0024050)

Definition (NCI) Bleeding from the lower gastrointestinal tract (small intestine, large intestine, and anus).
Definition (NCI_CTCAE) A disorder characterized by bleeding from the lower gastrointestinal tract (small intestine, large intestine, and anus).
Concepts Pathologic Function (T046)
SnomedCT 87763006
English Lower GIT - haemorrhage, Lower GIT - hemorrhage, Lower gastrointest haemorrh, Lower gastrointestinal hemorrhage, Lower Gastrointestinal Hemorrhage, lower gastrointestinal bleed, lower gastrointestinal bleeding, lower gi bleed, bleeding gastrointestinal lower, bleeding gi lower, lower gi bleeding, Intestinal hemorrhage, Lower gastrointestinal bleeding, Lower GIT - gastrointestinal haemorrhage, Lower GIT - gastrointestinal hemorrhage, Lower gastrointestinal haemorrhage, Lower GI bleeding, Lower GI haemorrhage, Lower GI hemorrhage, Lower gastrointestinal hemorrhage (disorder)
Italian Emorragia del tratto gastrointestinale inferiore, Sanguinamento del tratto gastrointestinale inferiore
French Hémorragie gastrointestinale basse, Saignement gastro-intestinal bas, Hémorragie gastro-intestinale basse
German unterer Gastrointestinaltrakt, Blutung, Bluten im unteren Gastrointestinaltrakt, Blutung im unteren Gastrointestinaltrakt
Portuguese Hemorragia gastrintestinal baixa, Sangramento gastrointestinal baixo, Hemorragia gastrointestinal inferior
Spanish Hemorragia gastrointestinal baja, Sangrado digestivo bajo, HDB, hemorragia GI inferior, hemorragia digestiva baja (trastorno), hemorragia digestiva baja, hemorragia gastrointestinal baja, hemorragia gastrointestinal inferior, sangrado GI inferior, sangrado gastrointestinal inferior, Hemorragia digestiva baja
Japanese 下部消化管出血, カブショウカカンシュッケツ
Czech Krvácení v dolní části zažívacího traktu, Krvácení z dolní části zažívacího traktu
Hungarian Alsó gastrointestinalis vérzés, Alsó gasztrointesztinalis vérzés
Dutch bloeding van onderste deel van maag-darmkanaal, onderste maagdarmkanaalbloeding

Ontology: Rectal hemorrhage (C0267596)

Definition (NCI_CTCAE) A disorder characterized by bleeding from the rectal wall and discharged from the anus.
Definition (NCI) Bleeding originating from the rectal wall and discharged from the anus.
Concepts Pathologic Function (T046)
SnomedCT 12063002, 197220006, 155804001, 197219000, 266532006
LNC LA17248-8
English RECTUM BLEEDING, RECTAL BLEEDING, HAEMORRHAGE RECTUM, HEMORRHAGE RECTUM, Rectal hemorrhage, Hemorrhage of rectum, rectal hemorrhage, rectal hemorrhage (diagnosis), Bleeding rectal, Rectal blood loss, Haemorrhage rectum, Hemorrhage rectal, Hemorrhage rectum, Bleeding;anal, Bleeding;rectal, rectorrhagia, rectal bleed, rectal blood loss, rectum bleeding, bleeding per rectum, bleeding rectum, rectal bleeding, rectum hemorrhage, Bleeding - rectal, Bleeding PR, Haemorrhage - rectal, Haemorrhage rectal, Hemorrhage - rectal, Rectal haemorrhage (disorder), Bleeding-rectal, Proctorrhagia, Rectorrhagia, Bleeding per rectum, PR - Bleeding per rectum, Rectal bleeding, Rectal haemorrhage, PRB - Rectal bleeding, RB - Rectal bleeding, PR - Blood per rectum, Blood per rectum, Rectal hemorrhage (disorder), hemorrhage; rectum, proctorrhagia, rectum; hemorrhage, Rectal Hemorrhage
Italian Emorragia del retto, Sanguinamento del retto, Rettorragia, Perdita di sangue dal retto, Proctorragia, Sanguinamento rettale
Dutch rectale bloeding, bloeding rectum, rectorragie, bloeding rectaal, proctorragie, hemorragie rectaal, rectaal bloedverlies, Rectaal bloedverlies, bloeding; rectum, rectum; bloeding, rectale hemorragie
French Rectorragie, Hémorragie du rectum, Perte de sang rectale, Proctorrhagie, Rectorrhagie, HEMORRAGIE RECTALE, RECTORRAGIE, Hémorragie rectale
German Blutung Rektum, Blutung rektal, rektale Blutung, Rektorrhagie, rektaler Blutverlust, Proktorrhagie, BLUTUNG REKTAL, REKTALE BLUTUNG, Rektalblutung
Portuguese Rectorragia, Hemorragia do recto, Perda rectal de sangue, Proctorragia, HEMORRAGIA RECTAL, RECTO HEMORRAGICO, Hemorragia rectal
Spanish Hemorragia de recto, Sangrado rectal, Hemorragia del recto, Proctorragia, Pérdida de sangre rectal, Rectorragia, HEMORRAGIA RECTAL, RECTORRAGIA, hemorragia del recto, hemorragia rectal, proctorragia (trastorno), proctorragia, rectorragia, sangrado por el recto, sangrado rectal, Hemorragia rectal
Japanese 直腸出血, 肛門直腸出血, チョクチョウシュッケツ, コウモンチョクチョウシュッケツ
Czech Krvácení rektální, Krvácení z rekta, Konečníkové krvácení, Krvácení z konečníku, Rektální krvácení, Ztráta krve z konečníku, Rektoragie
Hungarian Rectalis vérvesztés, Vérzés, rectalis, Rectorrhagia, Rectum-haemorrhagia, Rectum vérzés, Végbél eredetű haemorrhagia, Rectalis vérzés, Rectum vérzése, Proctorrhagia

Ontology: Bleeding from anus (C0426747)

Definition (NCI_CTCAE) A disorder characterized by bleeding from the anal region.
Definition (NCI) Bleeding originating from the anal area.
Concepts Pathologic Function (T046)
SnomedCT 6072007, 197221005
English Anal haemorrhage, Anal hemorrhage, Anal bleeding, Bleeding from anus, Hemorrhage of anus, anal hemorrhage, anal hemorrhage (diagnosis), Anal Hemorrhage, bleeding anal, anus bleed, anal bleed, bleeding anus, anal bleeding, anus bleeding, bleeding from anus, Anal hemorrhage (disorder), Bleeding from anus (disorder), hemorrhage; anus, anus; hemorrhage
Italian Emorragia anale, Sanguinamento anale
Dutch anale bloeding, anus; bloeding, bloeding; anus, anale hemorragie
French Saignement anal, Hémorragie anale
German anale Blutung, Analblutung
Spanish Sangrado anal, sangrado anal (trastorno), sangrado anal, hemorragia anal, hemorragia del ano (trastorno), hemorragia del ano, Hemorragia anal
Japanese 肛門出血, コウモンシュッケツ
Czech Řitní krvácení, Anální krvácení
Hungarian Analis vérzés, Végbélvérzés
Portuguese Hemorragia anal