Lower GI Bleeding: Epidemiology and Diagnosis

https://doi.org/10.1016/j.gtc.2005.08.007Get rights and content

Section snippets

Incidence

Acute LGIB is one of the most common gastrointestinal indications for hospital admission. The annual incidence of hospitalization for LGIB was estimated to be 20 to 30 per 100,000 persons in a large, southern California health maintenance organization [1]. This rate increased dramatically with advancing age [1]. Consequently, the impact of this disorder promises to increase as the population ages. In comparison, in the same population, the annual incidence of hospitalization for acute upper

Diagnostic Criteria

Multiple factors make the identification of a precise bleeding source in LGIB challenging. These include the diversity of potential sources, the length of bowel involved, the need for colon cleansing, and the intermittent nature of bleeding. In up to 40% of patients with LGIB, more than one potential bleeding source will be noted [31], and stigmata of recent bleeding in LGIB are infrequently identified (see Refs. [12], [13], [17]). As a result, no definitive source will be found in a large

Colonoscopy

Advances in endoscopic technology have brought colonoscopy to the forefront of the management of LGIB. Recent studies have shown that colonoscopy, particularly when performed early (within 12 to 24 hours of admission), is safe and effective (see Refs. [7], [9], [12], [13], [31]). Colonoscopy is undoubtedly the best test for confirming the source of LGIB and for excluding ominous diagnoses, such as malignancy. The diagnostic yield of colonoscopy ranges from 45% to 95% (Table 2) [6], [13].

Sources of Bleeding

Lower gastrointestinal bleeding arises from a diverse range of sources. Table 6 displays the breakdown of sources from a number of large studies. The spectrum of sources appears to be changing over time [16], [89]. In the early 20th century, neoplasia was reported as the predominant source of LGIB, and diverticular bleeding was presumably rare [16]. Angiodysplasia were increasingly recognized as a source of LGIB in the 1960s and 1970s [16]. Currently, diverticular bleeding is the leading source

Summary

Lower gastrointestinal bleeding is one of the most common gastrointestinal indications for hospital admission, particularly in the elderly. Diverticulosis accounts for up to 50% of cases, followed by ischemic colitis and anorectal lesions. Though most patients stop bleeding spontaneously and have favorable outcomes, long-term recurrence is a substantial problem for patients with bleeding from diverticulosis and angiodysplasia. The management of LGIB is challenging because of the diverse range

First page preview

First page preview
Click to open first page preview

References (114)

  • G.R. Zuckerman et al.

    Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes

    Gastrointest Endosc

    (1999)
  • K.D. Fine et al.

    Comparison of the color of fecal blood with the anatomical location of gastrointestinal bleeding lesions: potential misdiagnosis using only flexible sigmoidoscopy for bright red blood per rectum

    Am J Gastroenterol

    (1999)
  • W.N. Segal et al.

    The outpatient evaluation of hematochezia

    Am J Gastroenterol

    (1998)
  • D.J. Graham et al.

    Colonoscopy for intermittent rectal bleeding: impact on patient management

    J Surg Res

    (1993)
  • J.A. Snook et al.

    Value of a simple biochemical ratio in distinguishing upper and lower sites of gastrointestinal haemorrhage

    Lancet

    (1986)
  • D.M. Jensen et al.

    Colonoscopy for diagnosis and treatment of severe lower gastrointestinal bleeding. Routine outcomes and cost analysis

    Gastrointest Endosc Clin N Am

    (1997)
  • G.C. Jiranek et al.

    A cost-effective approach to the patient with peptic ulcer bleeding

    Surg Clin North Am

    (1996)
  • J.G. Lee et al.

    Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial

    Gastrointest Endosc

    (1999)
  • T.A. Colacchio et al.

    Impact of modern diagnostic methods on the management of active rectal bleeding. Ten-year experience

    Am J Surg

    (1982)
  • L.L. Strate et al.

    Predictors of utilization of early colonoscopy vs. radiography for severe lower intestinal bleeding

    Gastrointest Endosc

    (2005)
  • K.A. Forde

    Colonoscopy in acute rectal bleeding

    Gastrointest Endosc

    (1981)
  • J.M. Hunter et al.

    Limited value of technetium 99m-labeled red cell scintigraphy in localization of lower gastrointestinal bleeding

    Am J Surg

    (1990)
  • J.A. Markisz et al.

    An evaluation of 99mTc-labeled red blood cell scintigraphy for the detection and localization of gastrointestinal bleeding sites

    Gastroenterology

    (1982)
  • R. Gunderman et al.

    Diagnostic imaging and the outcome of acute lower gastrointestinal bleeding

    Acad Radiol

    (1998)
  • R.S. Bloomfeld et al.

    Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin

    Am J Gastroenterol

    (2000)
  • J.M. Ryan et al.

    Nonlocalized lower gastrointestinal bleeding: provocative bleeding studies with intraarterial tPA, heparin, and tolazoline

    J Vasc Interv Radiol

    (2001)
  • M. Pennazio et al.

    Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases

    Gastroenterology

    (2004)
  • A. Rastogi et al.

    Diagnostic yield and clinical outcomes of capsule endoscopy

    Gastrointest Endosc

    (2004)
  • D.G. Adler et al.

    A prospective comparison of capsule endoscopy and push enteroscopy in patients with GI bleeding of obscure origin

    Gastrointest Endosc

    (2004)
  • G. Costamagna et al.

    A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease

    Gastroenterology

    (2002)
  • L. Laine et al.

    Serious lower gastrointestinal clinical events with nonselective NSAID or coxib use

    Gastroenterology

    (2003)
  • J.R. Scharff et al.

    Ischemic colitis: spectrum of disease and outcome

    Surgery

    (2003)
  • S.J. Boley et al.

    On the nature and etiology of vascular ectasias of the colon. Degenerative lesions of aging

    Gastroenterology

    (1977)
  • M.S. Bhutani et al.

    A prospective controlled evaluation of endoscopic detection of angiodysplasia and its association with aortic valve disease

    Gastrointest Endosc

    (1995)
  • T.F. Imperiale et al.

    Aortic stenosis, idiopathic gastrointestinal bleeding, and angiodysplasia: is there an association? A methodologic critique of the literature

    Gastroenterology

    (1988)
  • G.F. Longstreth

    Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study

    Am J Gastroenterol

    (1997)
  • G.F. Longstreth

    Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study

    Am J Gastroenterol

    (1995)
  • M.H. Kollef et al.

    BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage

    Crit Care Med

    (1997)
  • D.A. Peura et al.

    The American College of Gastroenterology Bleeding Registry: preliminary findings

    Am J Gastroenterol

    (1997)
  • A.R. Al Qahtani et al.

    Investigative modalities for massive lower gastrointestinal bleeding

    World J Surg

    (2002)
  • V. Chaudhry et al.

    Colonoscopy: the initial test for acute lower gastrointestinal bleeding

    Am Surg

    (1998)
  • L.L. Strate et al.

    Early predictors of severity in acute lower intestinal tract bleeding

    Arch Intern Med

    (2003)
  • D.M. Jensen et al.

    Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage

    N Engl J Med

    (2000)
  • N.S. Painter et al.

    Diverticular disease of the colon: a deficiency disease of Western civilization

    BMJ

    (1971)
  • M. Bokhari et al.

    Diverticular hemorrhage in the elderly—is it well tolerated?

    Dis Colon Rectum

    (1996)
  • W. Browder et al.

    Impact of emergency angiography in massive lower gastrointestinal bleeding

    Ann Surg

    (1986)
  • I.M. Leitman et al.

    Evaluation and management of massive lower gastrointestinal hemorrhage

    Ann Surg

    (1989)
  • R. Levy et al.

    Retrospective study of the utility of nuclear scintigraphic-labelled red cell scanning for lower gastrointestinal bleeding

    ANZ J Surg

    (2003)
  • M.S. Suzman et al.

    Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy

    Ann Surg

    (1996)
  • H.H. McGuire

    Bleeding colonic diverticula. A reappraisal of natural history and management

    Ann Surg

    (1994)
  • Cited by (0)

    The author is supported by a grant (K08 HS014062-01) from the Agency for Healthcare Research and Quality, Rockville, MD.

    View full text