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Lower Gastrointestinal Bleeding
Aka: Lower Gastrointestinal Bleeding, Lower GI Bleed, Lower Gastrointestinal Hemorrhage, Rectal Bleeding, Anal Bleeding, Rectal Hemorrhage
- See Also
- Gastrointestinal Bleeding
- Upper Gastrointestinal Bleeding
- Diverticular Bleeding
- Definitions
- Lower Gastrointestinal Bleeding
- Bleeding distal to the ligament of treitz (suspends the distal duodenum) at the duodenojejunal flexure
- Epidemiology
- Incidence: 20 to 30 per 100,000 patients
- Hospital admission rate: 20 to 30 per 100,000 patients
- Lower GI Tract accounts for 20-24% of Gastrointestinal Bleeding sources
- History
- See Gastrointestinal Bleeding
- Causes: Adults with Acute Massive Rectal Bleeding
- Precaution: Consider Upper Gastrointestinal Bleeding source
- Diverticular Bleeding (10-20%, up to 40% of cases in some studies)
- Acute, severe painless bleeding, especially with known Diverticular Disease (approaches 50% in over age 60 years)
- Increased risk with advancing age and comorbidities (e.g. CAD, CKD, DM, Cirrhosis, cancer)
- Increased risk with NSAIDs, Aspirin and other antiplatelet agents (e.g. Plavix)
- Bleeding spontaneously ceases in 75%, recurs in 38%
- Recurrence is 9% at one year and 25% at 4 years
- Angiodysplasia, angioectasias or Arteriovenous Malformations (3-12%)
- Recurrent painless bleeding, especially in over age over 60 years
- Self resolves in 40-45% of cases, and persistent cases are treated with endoscopic coagulation or electrocautery
- Colon Cancer (2-26%)
- Slow chronic blood loss with change in bowel habits
- Inflammatory Bowel Disease (10%)
- Bloody Diarrhea with recurrent Abdominal Pain and weight loss
- Ischemic Colitis
- Self-limited bloody Diarrhea, followed by acute, recurrent lower Abdominal Pain and weight loss
- Seen in cardiovascular disease patients
- May be foretold by prior hypotensive event
- Rectal ulcer (hard stool induced Pressure Ulcers)
- Acute Infectious Colitis
- Bloody Diarrhea with fever (Inflammatory Diarrhea or Dysentery), and travel history or food exposures
- Causes include Campylobacter jejuni (most common Bacteria), Salmonella, Shigella, Shiga-toxin producing E. coli
- Other inflammatory causes include Clostridium difficile, Entamoeba histolytica and Yersinia
- Pseudomembranous colitis (or other Infectious Diarrhea or Dysentery)
- Bloody Diarrhea with fever and risk factors (recent antibiotics, suspect oral intakes)
- Radiation Colitis
- May be delayed 3 years after Radiation Therapy
- Post-polypectomy bleeding
- Self-limited bleeding, usually follows polypectomy or other bowel procedure within 30 days
- Associated with restarting NSAID or Aspirin too soon after Colonoscopy with polypectomy
- Aortoenteric Fistula (Aortic Graft-Enteric Fistula)
- Occurs in those with aortic surgery history
- Requires immediate emergency management
- Internal Hemorrhoid (<10%)
- External Hemorrhoids may also cause bleeding, but are painful and with obvious source unlike Internal Hemorrhoids
- See evaluation below regarding precautions in attributing Gastrointestinal Bleeding to Hemorrhoids
- More common at ages 45-65 years old
- Causes: Adults with chronic intermittent GI Bleeding
- Hemorrhoids (Up to 59%, includes external and Internal Hemorrhoids)
- Colorectal polyps (38 to 52%)
- Diverticulosis (34 to 51%)
- Colorectal Cancer (up to 8%)
- Ulcerative Colitis
- Arteriovenous Malformations
- Colonic stricture
- Causes: Adults - most commonly missed lower GI sources
- Arteriovenous Malformations
- Neoplasms in colon
- Causes: Children
- Anal Fissure
- Infectious Colitis
- Inflammatory Bowel Disease
- Polyps
- Intussusception
- Meckel's Diverticulum
- Signs
- Hematochezia (bright red blood in stool)
- Upper Gastrointestinal Bleeding source in 5-11% of patients
- Normal Bowel Sounds
- Hemodynamic status more stable than in Upper GI Bleed
- Orthostasis may however be seen in one third of patients
- Brisk, life-threatening bleeding may still occur in Lower GI Bleeding (e.g. Diverticular Bleeding)
- Nasogastric lavage and aspirate is clear except for bile
- Not typically recommended to differentiate upper from lower GI source (poor efficacy)
- Nasogastric aspirate is in contrast positive in Upper Gastrointestinal Bleeding
- Labs
- Serum Electrolytes
- BUN to Creatinine ratio >33 suggests Upper Gastrointestinal Bleeding source
- Normal Renal Function tests (BUN to Creatinine ratio normal) is typically normal in Lower Gastrointestinal Bleeding
- However, prerenal Azotemia may also occur in Dehydration (e.g. Acute Inflammatory Diarrhea)
- Complete Blood Count
- Hemoglobin or Hematocrit decreased in 50% of patients
- Usually less depressed than in Upper Gastrointestinal Bleeding
- Coaulation Studies
- Partial Thromboplastin Time (PTT)
- Prothrombin Time (PT/INR)
- Preparation for Blood Transfusion
- Consent for Blood Products
- Type and Crossmatch for Packed Red Blood Cells (pRBC)
- Assessment of comorbidity and secondary complications
- Electrocardiogram (EKG)
- Troponin
- Other diagnostic tests
- Fecal Calprotectin
- Indicated in the evaluation of Inflammatory Bowel Disease (positive if >250 mcg/g)
- Acute Inflammatory Diarrhea Causes
- Enteric Bacteria stool PCR testing
- Clostridium difficile Toxin (if recent antibiotics)
- Entamoeba histolytica (travel to tropical Africa, Asia or Latin America)
- Evaluation: Hemodynamically Unstable (Tachycardia, Hypotension)
- See stabilization in management below
- Criteria
- Heart Rate >100
- Systolic Blood Pressure <115 mmHg
- Capillary Refill >3 seconds
- Two or more comorbid conditions
- Evaluation: Hemodynamically Stable
- Painful Bleeding
- Fever, Diarrhea and possible exposures (food, recent travel)
- Infectious Colitis (Dysentery) evaluation with Stool Culture or enteric Bacteria and virus PCR panel
- Vascular disease risk factors in an older patient with pain out-of-proportion and symptoms recurrent with eating
- Ischemic bowel disease evaluation with CT Abdomen with contrast, Colonoscopy
- Intermittent Abdominal Pain, weight loss in a younger patient
- Inflammatory Bowel Disease evaluation with Fecal Calprotectin and Colonoscopy
- Pruritus Ani with bleeding occurs after stooling
- Evaluate for Hemorrhoids with Anoscopy (and ask patient to perform valsalva during exam)
- Anemia is rare with Hemorrhoidal bleeding
- Precaution: Bleeding Hemorrhoids may be concurrent with a more proximal, serious bleeding source
- Colonoscopy is not typically needed in suspected Hemorrhoids in age <40 without red flags
- Red flags include weight loss, fever, Anemia, colon cancer Family History, refractory course
- Painless Bleeding
- Intermittent bleeding with weight loss and changes in bowel habits
- Colon Cancer evaluation with Colonoscopy
- Acute painless bleeding with history of Diverticular Disease
- Diverticular Bleeding evaluation with Colonoscopy
- Polypectomy in the last 30 days
- Post-polypectomy bleeding evaluation with Colonoscopy
- Management: Acute Gastrointestinal Bleeding
- Precaution
- Brisk persistent bleeding occurs in up to 19% of cases
- Initial Stabilization
- Obtain early Consultation with Gastroenterology or General Surgery for brisk Gastrointestinal Bleeding
- ABC Management
- Oxygen Supplementation
- Obtain two large bore peripheral IVs (14-16 gauge)
- Obtain acute labs as above
- Stabilize with crystalloid (e.g. Normal Saline) as needed for hemodynamic instability while Blood Products pending
- However, blood is far preferred as soon as it is available
- Avoid excessive crystalloid prior to transfusion
- Telemetry monitoring with Heart Rate, Oxygen Saturation and Blood Pressure monitoring
- May also obtain Orthostatic Blood Pressure and Pulse if able (but poor efficacy)
- Transfuse Packed Red Blood Cells
- pRBC transfusion indicated for severe Anemia (Hemoglobin <7 g/dl)
- pRBC transfusion Indications for Hemoglobin <9 g/dl
- Symptomatic Anemia
- Continued heavy bleeding
- Ischemic cardiovascular disease or other affected comorbidity
- Consider Coagulopathy management
- See Emergent Reversal of Anticoagulation
- Prothrombin Complex Concentrate (PCC 4)
- Fresh Frozen Plasma (FFP)
- Platelet Transfusion
- Tranexamic Acid (lacks evidence of benefit)
- Antiplatelet agent management
- Continuing low dose Aspirin (e.g. 81 mg) has both risks and benefits
- Those with significant cardiovascular disease risk may continue Aspirin 81 mg daily
- Cardiovascular disease patients have fewer serious cardiovascular events on low dose Aspirin
- Low dose Aspirin is associated with increased risk of rebleeding after initial GI Bleeding event
- Low dose Aspirin use prior to endoscopy is associated with increased mortality in GI Bleeding
- However, Platelet function only improves 10%/day after stopping Aspirin
- Full return of Platelet function occurs at 10 days (Platelet lifetime) after stopping Aspirin
- Discontinue Dual Antiplatelet Therapy
- Continue low dose Aspirin
- Hold nonaspirin Antiplatelet Therapy for 1 to 7 days
- Obtain endoscopy (Colonoscopy and possible upper endoscopy if unclear source)
- See Colonoscopy in GI Bleeding
- Obtain Colonoscopy when patient is hemodynamically stable and with adequate Colonoscopy preparation
- Preparation with Polyethylene glycol 4 to 6 Liters over 3-4 hours until output without stool or blood
- Goal endoscopy timing is within 24 hours of significant acute Lower Gastrointestinal Bleeding
- Avoid tests without adequate yield in acute bleeding
- Avoid Flexible Sigmoidoscopy
- Avoid Barium Enema
- Consider Upper Gastrointestinal Bleeding source
- Upper GI Bleed with Hematochezia is always considered unstable
- BUN to Creatinine ratio increased >30-36 in Upper Gastrointestinal Bleeding (controversial reliability)
- Nasogastric lavage and aspirate is not typically recommended to differentiate source (low efficacy)
- Bleeding ceases spontaneously (occurs in 50% of cases)
- See Colonoscopy in GI Bleeding
- Evaluation may proceed outpatient in stable patient
- Colonoscopy negative: Consider Upper GI Bleed
- Brisk GI Bleeding obscures source on Colonoscopy (or too unstable for endoscopy)
- CT Angiography WITHOUT Oral Contrast (preferred)
- See CT Angiography in Gastrointestinal Bleeding
- May be test of choice in heavy Lower GI Bleeding in which endoscopy cannot be performed
- May direct exploratory laparotomy (identifying source)
- PACS imaging density >90 Hounsfield Units (HU) is consistent with blood on CTA
- Do not use high density oral or rectal contrast
- Oral Contrast obscures bleeding
- Oral Contrast not needed for other causes (e.g. Diverticulitis, ischemic bowel)
- Efficacy
- Test Sensitivity for Gastrointestinal Bleeding: 38% (similar to RBC Scan)
- CTA localizes the bleeding source in 53% (contrast with 30% for RBC Scan)
- CTA without bleeding predicts lower recurrent bleeding rate
- References
- Broder (2022) Crit Dec Emerg Med 31(2): 14-5
- Feuerstein (2016) AJR Am J Roentgenol 207(3): 578-84 [PubMed]
- Kennedy (2010) J Vasc Interv Radiol 21(6):848-55 [PubMed]
- Chan (2015) Cardiovasc Intervent Radiol 28(2): 329-35 [PubMed]
- Angiography in GI Bleeding
- Percutaneous catheter arteriography and embolization
- Consider as second-line test if bleeding persists and source not identified
- Radionuclide Red Cell Scan (Technetium Tc 99m-labeled RBC Scintigraphy)
- Less accurate, older procedure that is rarely performed now, and not typically recommended
- May be considered in hemodynamically stable patients in whom other methods are nondiagnostic
- More useful in slower bleeding (<0.4 ml/minute) but requires a minimum of 0.1 ml/min
- Immediate blush identifies high risk bleeding
- Ng (1997) Dis Colon Rectum 40:471-7 [PubMed]
- Slow continuous or recurrent bleeding
- See Colonoscopy in GI Bleeding
- No source on Colonoscopy
- Radionuclide Red Cell Scan: Positive
- See Angiography in GI Bleeding
- Consider repeat Colonoscopy in GI Bleeding
- Guided by red cell scan results
- Consider exploratory laparotomy
- See below for indications
- Radionuclide Red Cell Scan: Negative
- Consider Upper Endoscopy
- Evaluate for Hematochezia due to Upper GI Bleed
- These cases are always hemodynamically unstable
- Consider Small Intestinal Bleeding
- Exploratory laparotomy
- Adjunctive intraoperative measures
- Intraoperative Colonoscopy
- Intraoperative angiography
- Subtotal colectomy is a a procedure of last resort
- Indicated only in uncontrolled Massive Hemorrhage where no alternative management exists
- High morbidity and mortality associated with emergent subtotal colectomy
- Indications
- Transfusion >4 units in 24 hours
- Transfusion >10 units total
- Recurrent bleeding episodes
- Comorbid conditions significantly affected
- Management: Asymptomatic mild Rectal Bleeding (clinic)
- Age over 35 years: Colonoscopy
- Age 25 to 35 years: Diagnostics based on risk factors
- Age under 25 years: Anoscopy, Flexible Sigmoidoscopy
- Lewis (2002) Ann Intern Med 136:99-110 [PubMed]
- Prognosis
- Overall mortality 4%
- Mortality may approach 20% if admitted for comorbidity
- References
- Demarkles (1993) Med Clin North Am 77(5):1085-100 [PubMed]
- Fallah (2000) Med Clin North Am 84(5):1183-208 [PubMed]
- Hawks (2020) Am Fam Physician 101(4): 206-12 [PubMed]
- Manten (1995) Postgrad Med 97(4):154-7 [PubMed]
- Morris (2020) Crit Dec Emerg Med 34(8): 9 [PubMed]
- Peter (1999) Emerg Med Clin North Am 17(1):239-61 [PubMed]
- Zuckerman (2000) Gastroenterology 118:201-21 [PubMed]