Gastroenterology Book

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Lower Gastrointestinal Bleeding

Aka: Lower Gastrointestinal Bleeding, Lower GI Bleed, Lower Gastrointestinal Hemorrhage, Rectal Bleeding, Anal Bleeding, Rectal Hemorrhage
  1. See Also
    1. Gastrointestinal Bleeding
    2. Upper Gastrointestinal Bleeding
    3. Diverticular Bleeding
  2. Definitions
    1. Lower Gastrointestinal Bleeding
      1. Bleeding distal to the ligament of treitz (suspends the distal duodenum) at the duodenojejunal flexure
  3. Epidemiology
    1. Incidence: 20 to 30 per 100,000 patients
    2. Hospital admission rate: 20 to 30 per 100,000 patients
    3. Lower GI tract accounts for 20-24% of Gastrointestinal Bleeding sources
  4. History
    1. See Gastrointestinal Bleeding
  5. Causes: Adults with Acute Massive Rectal Bleeding
    1. Precaution: Consider Upper Gastrointestinal Bleeding source
    2. Diverticular Bleeding (10-20%, up to 40% of cases in some studies)
      1. Acute, severe painless bleeding, especially with known Diverticular Disease (approaches 50% in over age 60 years)
      2. Increased risk with advancing age and comorbidities (e.g. CAD, CKD, DM, Cirrhosis, cancer)
      3. Increased risk with NSAIDs, Aspirin and other antiplatelet agents (e.g. Plavix)
      4. Bleeding spontaneously ceases in 75%, recurs in 38%
      5. Recurrence is 9% at one year and 25% at 4 years
    3. Angiodysplasia, angioectasias or arteriovenous malformations (3-12%)
      1. Recurrent painless bleeding, especially in over age over 60 years
      2. Self resolves in 40-45% of cases, and persistent cases are treated with endoscopic coagulation or electrocautery
    4. Colon Cancer (2-26%)
      1. Slow chronic blood loss with change in bowel habits
    5. Inflammatory Bowel Disease (10%)
      1. Bloody Diarrhea with recurrent Abdominal Pain and weight loss
    6. Ischemic Colitis
      1. Self-limited bloody Diarrhea, followed by acute, recurrent lower Abdominal Pain and weight loss
      2. Seen in cardiovascular disease patients
      3. May be foretold by prior hypotensive event
    7. Rectal ulcer (hard stool induced Pressure Ulcers)
    8. Acute Infectious Colitis
      1. Bloody Diarrhea with fever (inflammatory Diarrhea or Dysentery), and travel history or food exposures
      2. Causes include Campylobacter jejuni (most common Bacteria), Salmonella, Shigella, Shiga-toxin producing E. coli
      3. Other inflammatory causes include Clostridium difficile, Entamoeba histolytica and Yersinia
    9. Pseudomembranous colitis (or other Infectious Diarrhea or dysentary)
      1. Bloody Diarrhea with fever and risk factors (recent antibiotics, suspect oral intakes)
    10. Radiation Colitis
      1. May be delayed 3 years after Radiation Therapy
    11. Post-polypectomy bleeding
      1. Self-limited bleeding, usually follows polypectomy or other bowel procedure within 30 days
      2. Associated with restarting NSAID or Aspirin too soon after Colonoscopy with polypectomy
    12. Aortoenteric fistula (Aortic graft-enteric fistula)
      1. Occurs in those with aortic surgery history
      2. Requires immediate emergency management
    13. Internal Hemorrhoid (<10%)
      1. External Hemorrhoids may also cause bleeding, but are painful and with obvious source unlike Internal Hemorrhoids
      2. See evaluation below regarding precautions in attributing Gastrointestinal Bleeding to Hemorrhoids
      3. More common at ages 45-65 years old
  6. Causes: Adults with chronic intermittent GI Bleeding
    1. Hemorrhoids (Up to 59%, includes external and Internal Hemorrhoids)
    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
  7. Causes: Adults - most commonly missed lower GI sources
    1. Arteriovenous malformations
    2. Neoplasms in colon
  8. Causes: Children
    1. Anal Fissure
    2. Infectious Colitis
    3. Inflammatory Bowel Disease
    4. Polyps
    5. Intussusception
    6. Meckel's Diverticulum
  9. Signs
    1. Hematochezia (bright red blood in stool)
      1. Upper Gastrointestinal Bleeding source in 5-11% of patients
    2. Normal Bowel Sounds
    3. Hemodynamic status more stable than in Upper GI Bleed
      1. Orthostasis may however be seen in one third of patients
      2. Brisk, life-threatening bleeding may still occur in Lower GI Bleeding (e.g. Diverticular Bleeding)
    4. Nasogastric lavage and aspirate is clear except for bile
      1. Not typically recommended to differentiate upper from lower GI source (poor efficacy)
      2. Nasogastric aspirate is in contrast positive in Upper Gastrointestinal Bleeding
  10. Labs
    1. Serum electrolytes
      1. BUN to Creatinine ratio >33 suggests Upper Gastrointestinal Bleeding source
      2. Normal Renal Function tests (BUN to Creatinine ratio normal) is typically normal in Lower Gastrointestinal Bleeding
        1. However, prerenal Azotemia may also occur in dehydration (e.g. Acute Inflammatory Diarrhea)
    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
    6. Other diagnostic tests
      1. Fecal Calprotectin
        1. Indicated in the evaluation of Inflammatory Bowel Disease (positive if >250 mcg/g)
      2. Acute Inflammatory Diarrhea Causes
        1. Enteric Bacteria stool PCR testing
        2. Clostridium difficile Toxin (if recent antibiotics)
        3. Entamoeba histolytica (travel to tropical Africa, Asia or Latin America)
  11. Evaluation: Hemodynamically Unstable (Tachycardia, Hypotension)
    1. See stabilization in management below
    2. Criteria
      1. Heart Rate >100
      2. Systolic Blood Pressure <115 mmHg
      3. Capillary Refill >3 seconds
      4. Two or more comorbid conditions
  12. Evaluation: Hemodynamically Stable
    1. Painful Bleeding
      1. Fever, Diarrhea and possible exposures (food, recent travel)
        1. Infectious Colitis (Dysentery) evaluation with Stool Culture or enteric Bacteria and virus PCR panel
      2. Vascular disease risk factors in an older patient with pain out-of-proportion and symptoms recurrent with eating
        1. Ischemic bowel disease evaluation with CT Abdomen with contrast, Colonoscopy
      3. Intermittent Abdominal Pain, weight loss in a younger patient
        1. Inflammatory Bowel Disease evaluation with Fecal Calprotectin and Colonoscopy
      4. Pruritus Ani with bleeding occurs after stooling
        1. Evaluate for Hemorrhoids with Anoscopy (and ask patient to perform valsalva during exam)
        2. Anemia is rare with Hemorrhoidal bleeding
        3. Precaution: Bleeding Hemorrhoids may be concurrent with a more proximal, serious bleeding source
          1. Colonoscopy is not typically needed in suspected Hemorrhoids in age <40 without red flags
          2. Red flags include weight loss, fever, Anemia, colon cancer Family History, refractory course
    2. Painless Bleeding
      1. Intermittent bleeding with weight loss and changes in bowel habits
        1. Colon Cancer evaluation with Colonoscopy
      2. Acute painless bleeding with history of Diverticular Disease
        1. Diverticular Bleeding evaluation with Colonoscopy
      3. Polypectomy in the last 30 days
        1. Post-polypectomy bleeding evaluation with Colonoscopy
  13. Management: Acute Gastrointestinal Bleeding
    1. Precaution
      1. Brisk persistent bleeding occurs in up to 19% of cases
    2. Initial Stabilization
      1. Obtain early Consultation with Gastroenterology or General Surgery for brisk Gastrointestinal Bleeding
      2. ABC Management
      3. Oxygen Supplementation
      4. Obtain two large bore peripheral IVs (14-16 gauge)
      5. Obtain acute labs as above
      6. 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. Telemetry monitoring with Heart Rate, Oxygen Saturation and Blood Pressure monitoring
        1. May also obtain Orthostatic Blood Pressure and Pulse if able (but poor efficacy)
      8. Transfuse Packed Red Blood Cells
        1. Indicated for severe Anemia (Hemoglobin <7 g/dl)
        2. Indicated for symptomatic Anemia or continued heavy bleeding (Hemoglobin <9 g/dl)
      9. Consider Coagulopathy management
        1. Prothrombin Complex Concentrate (PCC 4)
        2. Fresh Frozen Plasma (FFP)
        3. Platelet Transfusion
        4. Tranexamic Acid (lacks evidence of benefit)
    3. Obtain endoscopy (Colonoscopy and possible upper endoscopy if unclear source)
      1. Obtain Colonoscopy when patient is hemodynamically stable and with adequate Colonoscopy preparation
        1. Preparation with Polyethylene glycol 4 to 6 Liters over 3-4 hours until output without stool or blood
      2. Avoid tests without adequate yield in acute bleeding
        1. Avoid Flexible Sigmoidoscopy
        2. Avoid Barium Enema
      3. Consider Upper Gastrointestinal Bleeding source
        1. Upper GI Bleed with Hematochezia is always considered unstable
        2. BUN to Creatinine ratio increased in Upper Gastrointestinal Bleeding
        3. Nasogastric lavage and aspirate is not typically recommended to differentiate source (low efficacy)
    4. 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
    5. Brisk GI Bleeding obscures source on Colonoscopy (or too unstable for endoscopy)
      1. CT Angiography (preferred)
        1. See Angiography in GI Bleeding
        2. May be test of choice in heavy Lower GI Bleeding in which endoscopy cannot be performed
        3. May direct exploratory laparotomy
      2. Percutaneous catheter arteriography and embolization
        1. Consider as second-line test if bleeding persists and source not identified
      3. Radionuclide Red Cell Scan (Technetium Tc 99m-labeled RBC Scintigraphy)
        1. Less accurate, older procedure that is rarely performed now, and not typically recommended
        2. May be considered in hemodynamically stable patients in whom other methods are nondiagnostic
        3. More useful in slower bleeding (<0.4 ml/minute) but requires a minimum of 0.1 ml/min
        4. Immediate blush identifies high risk bleeding
          1. Ng (1997) Dis Colon Rectum 40:471-7 [PubMed]
    6. 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
    7. 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
  14. 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]
  15. Prognosis
    1. Overall mortality 4%
    2. Mortality may approach 20% if admitted for comorbidity
  16. References
    1. Demarkles (1993) Med Clin North Am 77(5):1085-100 [PubMed]
    2. Fallah (2000) Med Clin North Am 84(5):1183-208 [PubMed]
    3. Hawks (2020) Am Fam Physician 101(4): 206-12 [PubMed]
    4. Manten (1995) Postgrad Med 97(4):154-7 [PubMed]
    5. Peter (1999) Emerg Med Clin North Am 17(1):239-61 [PubMed]
    6. Zuckerman (2000) Gastroenterology 118:201-21 [PubMed]

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
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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