Chapter 76: Lower Gastrointestinal Bleeding

INTRODUCTION AND EPIDEMIOLOGY

Lower GI (LGI) bleeding is the loss of blood from the GI tract distal to the ligament of Treitz. LGI bleeding is a common problem in emergency medicine and should be considered potentially life threatening until proven otherwise.

LGI bleeding occurs less often than upper GI (UGI) bleeding, with an annual incidence of approximately 36 per 100,000.¹ Because blood must travel through the UGI tract down to the LGI system, UGI bleeds are the most common source for all causes of blood detected in the LGI system. Among patients with an established LGI source of bleeding (i.e., bleeding past the ligament of Treitz), the most common cause is diverticular disease, followed by colitis, adenomatous polyps, and malignancies.^2,3 LGI bleeding is more common among females and increases significantly in the elderly.¹

About 80% of episodes of LGI bleeding resolve spontaneously.⁴ However, one cannot predict which episodes will spontaneously resolve or which episodes will result in complications. This is partly due to the difficulty in establishing a pathophysiologic diagnosis. In one study, a cause for bleeding was found in <50% of the cases.⁵

PATHOPHYSIOLOGY

Hematochezia is either bright red or maroon-colored rectal bleeding. If hematochezia originates from a UGI source, it indicates brisk UGI bleeding, which may be accompanied by hematemesis and hemodynamic instability. Approximately 10% of hematochezia episodes may be associated with UGI bleeding.⁶ Melena is dark or black-colored stools and usually represents bleeding from a UGI source (proximal to the ligament of Treitz) but may also represent slow bleeding from an LGI source.

DIVERTICULOSIS

Diverticular bleeding is usually painless and results from erosion into the penetrating artery of the diverticulum. Diverticular bleeding may be massive, but up to 90% of episodes will resolve spontaneously. Bleeding can recur in up to half.^7,8 Although most diverticula are located on the left colon, right-sided diverticula are thought to be more likely to bleed.⁹ Elderly patients with underlying medical illnesses, those with increased needs for transfusion, and those taking anticoagulants or nonsteroidal anti-inflammatory drugs have increased morbidity and mortality.⁷

VASCULAR ECTASIA

Vascular ectasia, which includes arteriovenous malformations and angiodysplasias of the colon, is a common cause of LGI bleeding. Vascular ectasia can also be present in the small bowel and is difficult to diagnose. The development of vascular ectasia in the large bowel seems to be due to a chronic process and increases with aging. Inherited conditions can also give rise to arteriovenous malformations. There is also a suggestion that valvular heart disease is a risk factor for developing bleeding vascular ectasias, although this is an area of debate.⁴

ISCHEMIC COLITIS AND MESENTERIC ISCHEMIA

Ischemic colitis is the most common cause ...