Review Article | Published:

Diagnosis and management of lower gastrointestinal bleeding

Nature Reviews Gastroenterology & Hepatology volume 6, pages 637646 (2009) | Download Citation

Subjects

Abstract

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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References

  1. 1.

    Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am. J. Gastroenterol. 93, 1202–1208 (1998).

  2. 2.

    & Acute small bowel bleeding: a distinct entity with significantly different economic implications compared with GI bleeding from other locations. Gastrointest. Endosc. 58, 330–335 (2003).

  3. 3.

    et al. ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest. Endosc. 62, 656–660 (2005).

  4. 4.

    & Review article: the management of lower gastrointestinal bleeding. Aliment. Pharmacol. Ther. 21, 1281–1298 (2005).

  5. 5.

    , , & Epidemiology of acute lower intestinal bleeding [abstract]. Gastrointest. Endosc. 57, 93 (2003).

  6. 6.

    Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am. J. Gastroenterol. 92, 419–424 (1997).

  7. 7.

    , , & The American College of Gastroenterology Bleeding Registry: preliminary findings. Am. J. Gastroenterol. 92, 924–928 (1997).

  8. 8.

    & Acute lower intestinal bleeding: part I: clinical presentation and diagnosis. Gastrointest. Endosc. 48, 606–617 (1998).

  9. 9.

    & Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 95, 1569–1574 (1988).

  10. 10.

    , , , & A paradigm for consensus. The University Hospital Consortium guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions. Arch. Intern. Med. 155, 373–379 (1995).

  11. 11.

    Volume replacement in the surgical patient-does the type of solution make a difference? Br. J. Anaesth. 84, 783–793 (2000).

  12. 12.

    , , & Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N. Engl. J. Med. 342, 78–82 (2000).

  13. 13.

    , & Endoscopic therapy of acute diverticular hemorrhage. Am. J. Gastroenterol. 96, 2367–2372 (2001).

  14. 14.

    & Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest. Endosc. 49, 228–238 (1999).

  15. 15.

    , & Prevalence and natural history of colonic angiodysplasia among healthy asymptomatic people. Am. J. Gastroenterol. 90, 564–567 (1995).

  16. 16.

    , , & Angiodysplasia. Clinical presentation and colonoscopic diagnosis. Dig. Dis. Sci. 29, 481–485 (1984).

  17. 17.

    et al. Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up. Am. J. Gastroenterol. 101, 58–63 (2006).

  18. 18.

    , , & Angiodysplasia. Natural history and efficacy of therapeutic interventions. Dig. Dis. Sci. 34, 1542–1546 (1989).

  19. 19.

    Angiodysplasia of the gastrointestinal tract. Am. J. Gastroenterol. 88, 807–818 (1993).

  20. 20.

    & Ability of naloxone to enhance the colonoscopic appearance of normal colon vasculature and colon vascular ectasias. Gastrointest. Endosc. 49, 79–83 (1999).

  21. 21.

    & Masking of colon vascular ectasias by cold water lavage. Gastrointest. Endosc. 49, 141–142 (1999).

  22. 22.

    , , & Arteriovenous malformations (AVMs): are they concealed by meperidine [abstract]? Am. J. Gastroenterol. 86, 1552 (1991).

  23. 23.

    , , , & Rectal bleeding after conformal 3D treatment of prostate cancer: time to occurrence, response to treatment and duration of morbidity. Int. J. Radiat. Oncol. Biol. Phys. 39, 77–83 (1997).

  24. 24.

    , & Effect of pelvic radiotherapy for prostate cancer on bowel, bladder, and sexual function: the patient's perspective. Urology 47, 387–394 (1996).

  25. 25.

    & Gastrointestinal bleeding in patients with hereditary hemorrhagic telangiectasia. Am. J. Gastroenterol. 95, 415–418 (2000).

  26. 26.

    et al. Diagnosis and management of gastrointestinal bleeding in patients with hereditary hemorrhagic telangiectasia. Am. J. Gastroenterol. 98, 59–65 (2003).

  27. 27.

    , , & Risk factors for mortality in lower intestinal bleeding. Clin. Gastroenterol. Hepatol. 6, 1004–1010 (2008).

  28. 28.

    et al. Acute major gastrointestinal hemorrhage in inflammatory bowel disease. Gastrointest. Endosc. 49, 153–157 (1999).

  29. 29.

    , & Severe gastrointestinal hemorrhage in Crohn's disease. Ann. Surg. 213, 207–211 (1991).

  30. 30.

    , & Risk factors for recurrent bleeding and mortality in human immunodeficiency virus infected patients with acute lower GI hemorrhage. Gastrointest. Endosc. 49, 748–753 (1999).

  31. 31.

    , & Objective evidence of aspirin use in both ulcer and nonulcer upper and lower gastrointestinal bleeding. Gastroenterology 103, 862–869 (1992).

  32. 32.

    Acute and chronic lower gastrointestinal bleeding. in Atlas of Colonscopy (ed. Messmann, H.) 118–142 (Thieme, Stuttgart New York, 2006).

  33. 33.

    et al. Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am. J. Gastroenterol. 101, 1333–1341 (2006).

  34. 34.

    et al. Efficacy, risk factors and complications of endoscopic polypectomy: ten year experience at a single center. World J. Gastroenterol. 14, 2364–2369 (2008).

  35. 35.

    , , , & Risk factors for severe delayed postpolypectomy bleeding. Endoscopy 40, 115–119 (2008).

  36. 36.

    et al. Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors. Gastrointest. Endosc. 64, 73–78 (2006).

  37. 37.

    et al. Postpolypectomy colonic hemorrhage. Dis. Colon Rectum 39, 806–810 (1996).

  38. 38.

    , , 3rd & Hemorrhage following colonoscopic polypectomy. Dis. Colon Rectum 36, 1126–1131 (1993).

  39. 39.

    Fiberoptic colonoscopy: complications of colonoscopy and polypectomy. Dis. Colon Rectum. 19, 407–412 (1976).

  40. 40.

    , , & Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden. Gastrointest. Endosc. 54, 302–309 (2001).

  41. 41.

    et al. The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy 37, 1116–1122 (2005).

  42. 42.

    et al. Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases. Gastrointest. Endosc. 59, 44–48 (2004).

  43. 43.

    , , & The prevalence and spectrum of colonic lesions in patients with cirrhotic and noncirrhotic portal hypertension. Hepatology 21, 1226–1231 (1995).

  44. 44.

    et al. An annotated algorithmic approach to acute lower gastrointestinal bleeding. Gastrointest. Endosc. 53, 859–863 (2001).

  45. 45.

    , , & Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am. Surg. 64, 723–728 (1998).

  46. 46.

    et al. Analysis of urgent colonoscopy for lower gastrointestinal tract bleeding. Digestion 61, 189–192 (2000).

  47. 47.

    Urgent colonoscopy for acute lower-GI bleeding. Gastrointest. Endosc. 59, 402–408 (2004).

  48. 48.

    Video capsule endoscopy of the small bowel. Curr. Opin. Gastroenterol. 24, 159–163 (2008).

  49. 49.

    , , & The accuracy of technetium-99m-labeled red cell scintigraphy in localizing gastrointestinal bleeding. Am. J. Gastroenterol. 89, 345–348 (1994).

  50. 50.

    , & Massive hemorrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention. Am. J. Roentgenol. 161, 703–711 (1993).

  51. 51.

    & Radiographic demonstration of unknown sites of gastrointestinal bleeding. Surg. Forum 14, 374–375 (1963).

  52. 52.

    , , , & The diagnostic yield of superior mesenteric angiography: correlation with the pattern of gastrointestinal bleeding. Am. J. Gastroenterol. 84, 878–881 (1989).

  53. 53.

    , , & Complications of peripheral arteriography: a new system to identify patients at increased risk. J. Vasc. Surg. 22, 787–794 (1995).

  54. 54.

    et al. Accuracy of helical computed tomographic angiography for the diagnosis of colonic angiodysplasia. Gastroenterology 119, 293–299 (2000).

  55. 55.

    & Using biphasic CT to reveal gastrointestinal arteriovenous malformations. Am. J. Roentgenol. 168, 437–438 (1997).

  56. 56.

    et al. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology 239, 160–167 (2006).

  57. 57.

    et al. Helical CT in acute lower gastrointestinal bleeding. Eur. Radiol. 13, 114–117 (2003).

  58. 58.

    , , & MDCT of acute lower gastrointestinal bleeding. Am. J. Roentgenol. 182, 427–430 (2004).

  59. 59.

    et al. Which electrode? A comparison of four endoscopic methods of electrocoagulation in experimental bleeding ulcers. Gut 25, 1424–1431 (1984).

  60. 60.

    , , & The tissue effect of argon plasma coagulation on esophageal and gastric mucosa. Gastrointest. Endosc. 52, 342–345 (2000).

  61. 61.

    , & Therapeutic options for endoscopic haemostatic failures: the place of the surgeon and radiologist in gastrointestinal tract bleeding. Best Pract. Res. Clin. Gastroenterol. 22, 341–354 (2008).

  62. 62.

    et al. Superselective microcoil embolization of colonic hemorrhage. Am. J. Roentgenol. 177, 829–836 (2001).

  63. 63.

    , , & Percutaneous embolotherapy of lower gastrointestinal hemorrhage. J. Vasc. Interv. Radiol. 9, 747–751 (1998).

  64. 64.

    , & Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann. Surg. 204, 530–536 (1986).

  65. 65.

    3rd, , & Lower gastrointestinal bleeding. Dis. Colon Rectum 40, 846–858 (1997).

  66. 66.

    , & Octreotide in the treatment of bleeding due to angiodysplasia of the small intestine. Am. J. Gastroenterol. 88, 1424–1427 (1993).

  67. 67.

    , , & Treatment of bleeding due to diffuse angiodyplasia of the small intetsine with somatostaine analogue. Eur. J. Gastroenterol. Hepatol. 3, 785–787 (1991).

  68. 68.

    et al. Octreotide for severe acute bleeding from portal hypertensive colopathy: a case report. Eur. J. Gastroenterol. Hepatol. 13, 1111–1113 (2001).

  69. 69.

    , , & Thalidomide for treatment of severe intestinal bleeding. Gut 53, 609–612 (2004).

  70. 70.

    , & Early colonoscopy for acute lower GI bleeding predicts shorter hospital stay: a retrospective study of experience in a single center. Gastrointest. Endosc. 58, 841–846 (2003).

  71. 71.

    & Timing of colonoscopy: impact on length of hospital stay in patients with acute lower intestinal bleeding. Am. J. Gastroenterol. 98, 317–322 (2003).

  72. 72.

    et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am. J. Gastroenterol. 100, 2395–2402 (2005).

  73. 73.

    , , & Stigmata associated with recurrence of lower gastrointestinal hemorrhage [abstract]. Gastrointest. Endosc. 57, 117 (2003).

  74. 74.

    , & Triage considerations for patients with acute gastrointestinal hemorrhage admitted to a medical intensive care unit. Crit. Care Med. 23, 1048–1054 (1995).

  75. 75.

    , , & BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage. Crit. Care Med. 25, 1125–1132 (1997).

  76. 76.

    , & Early predictors of severity in acute lower intestinal tract bleeding. Arch. Intern. Med. 163, 838–843 (2003).

  77. 77.

    , , , & Validation of a clinical prediction rule for severe acute lower intestinal bleeding. Am. J. Gastroenterol. 100, 1821–1827 (2005).

  78. 78.

    et al. Prediction of outcome in acute lower-gastrointestinal haemorrhage based on an artificial neural network: internal and external validation of a predictive model. Lancet 362, 1261–1266 (2003).

  79. 79.

    & Gastrointestinal evaluation of anaemic patients without evidence of iron deficiency. Eur. J. Gastroenterol. Hepatol. 20, 1094–1100 (2008).

  80. 80.

    & Prospective evaluation of gastrointestinal tract in patients with iron-deficiency anemia. Dig. Dis. Sci. 40, 1283–1289 (1995).

  81. 81.

    & Prospective survey of investigations in outpatients referred with iron deficiency anaemia. Gut 34, 1102–1107 (1993).

  82. 82.

    & Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia. N. Engl. J. Med. 329, 1691–1695 (1993).

  83. 83.

    , & The role of endoscopy in the evaluation of iron deficiency anemia in patients over the age of 50. Am. J. Gastroenterol. 89, 1963–1967 (1994).

  84. 84.

    , & Direct current electrotherapy of internal hemorrhoids: an effective, safe, and painless outpatient approach. Am. J. Gastroenterol. 84, 482–487 (1989).

  85. 85.

    Band ligation for colonic bleeding: modification of multiband ligating devices for use with a colonoscope. Gastrointest. Endosc. 52, 762–765 (2000).

  86. 86.

    , , , & A randomized prospective study of endoscopic bipolar electrocoagulation and heater probe treatment of chronic rectal bleeding from radiation telangiectasia. Gastrointest. Endosc. 45, 20–25 (1997).

  87. 87.

    & Endoscopic management of acute lower gastrointestinal bleeding. Am. J. Gastroenterol. 103, 1881–1887 (2008).

  88. 88.

    & Endoscopic treatment of lower gastrointestinal bleeding. Curr. Opin. Gastroenterol. 18, 87–93 (2002).

  89. 89.

    et al. A case of ulcerative colitis with local bleeding treated by endoscopic injection of absolute etanaol and 1% polidocanol. Gastroenterol. Endosc. 4, 969–973 (1999).

  90. 90.

    et al. Endoscopic treatment of massive lower GI hemorrhage in two patients with ulcerative colitis. Gastrointest. Endosc. 54, 779–781 (2001).

  91. 91.

    et al. Prospective randomized comparative study of bipolar electrocoagulation versus heater probe for treatment of chronically bleeding internal hemorrhoids. Gastrointest. Endosc. 46, 435–443 (1997).

  92. 92.

    & Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am. J. Gastroenterol. 87, 1600–1606 (1992).

  93. 93.

    et al. Endoscopic therapy of anorectal disorders. Gastrointest. Endosc. 53, 867–870 (2001).

  94. 94.

    , , & A personal experience in comparing three nonoperative techniques for treating internal hemorrhoids. Am. J. Gastroenterol. 84, 488–492 (1989).

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Acknowledgements

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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Affiliations

  1. Department of Internal Medicine III, Klinikum Augsburg, Augsburg, Germany.

    • Jürgen Barnert
    •  & Helmut Messmann

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The authors declare no competing financial interests.

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Correspondence to Helmut Messmann.

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https://doi.org/10.1038/nrgastro.2009.167

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