Diagnosis and management of lower gastrointestinal bleeding

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Lower gastrointestinal bleeding (LGIB) can present as an acute and life-threatening event or as chronic bleeding, which might manifest as iron-deficiency anemia, fecal occult blood or intermittent scant hematochezia. Bleeding from the small bowel has been shown to be a distinct entity, and LGIB is defined as bleeding from a colonic source. Acute bleeding from the colon is usually less dramatic than upper gastrointestinal hemorrhage and is self-limiting in most cases. Several factors might contribute to increased mortality, a severe course of bleeding and recurrent bleeding, including advanced age, comorbidity, intestinal ischemia, bleeding as a result of a separate process, and hemodynamic instability. Diverticula, angiodysplasias, neoplasms, colitis, ischemia, anorectal disorders and postpolypectomy bleeding are the most common causes of LGIB. Volume resuscitation should take place concurrently upon initial patient assessment. Colonoscopy is the diagnostic and therapeutic procedure of choice, for acute and chronic bleeding. Angiography is used if colonoscopy fails or cannot be performed. The use of radioisotope scans is reserved for cases of unexplained intermittent bleeding, when other methods have failed to detect the source. Embolization or modern endoscopy techniques, such as injection therapy, thermocoagulation and mechanical devices, effectively promote hemostasis. Surgery is the final approach for severe bleeding.

Key Points

  • The severity of acute lower gastrointestinal bleeding (LGIB) is variable, but overall mortality is low

  • In most cases, bleeding will stop spontaneously

  • Mortality is higher in older adults, and in those with intestinal ischemia and other comorbidities

  • Colonoscopy is the diagnostic and therapeutic mainstay in the management of acute and chronic LGIB

  • Visceral angiography is the preferred diagnostic and therapeutic method in patients with hemodynamic instability

  • The existing scoring systems are time consuming and offer little help in clinical decision-making

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Figure 1
Figure 2
Figure 3: Algorithm showing recommended evaluation of acute lower gastrointestinal bleeding from initial presentation of the patient with hematochezia.


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Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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Correspondence to Helmut Messmann.

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Barnert, J., Messmann, H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 6, 637–646 (2009) doi:10.1038/nrgastro.2009.167

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