Lower gastrointestinal bleeding
Lower gastrointestinal bleeding | |
---|---|
Other names | LGIB |
A positive fecal occult blood test | |
Specialty | Gastroenterology |
Symptoms | bright blood in stool dark blood in vomit |
Lower gastrointestinal bleeding, commonly abbreviated LGIB, is any form of
Signs and symptoms
A lower gastrointestinal bleed is defined as bleeding originating distal to the
The
Occasionally, a person with a LGIB will not present with any signs of internal bleeding, especially if there is a chronic bleed with ongoing low levels of blood loss. In these cases, a diagnostic assessment or pre-assessment should watch for other signs and symptoms that the patient may present with. These include, but are not limited to,
Causes
The following are possible causes of a LGIB:
- Diverticular disease — diverticulosis, diverticulitis
- Colitis
- Ischaemic colitis
- Radiation colitis
- Infectious colitis
- Pseudomembranous colitis
- E. coli O157:H7
- Shigella
- Salmonella
- Campylobacter jejuni
- Hemorrhoids
- Neoplasm — such as colorectal cancer
- Angiodysplasia
- Bleeding from a site where a colonic polyp was removed
- Inflammatory bowel disease such as Crohn's disease or ulcerative colitis
- Rectal varices
- Coagulopathy — specifically a bleeding diathesis
- Anal fissures
- Rectal foreign bodies
- Mesenteric ischemia
- NSAIDs
- Entamoeba histolytica
- Stercoral ulceration
- Dieulafoy lesion(rare)
Diagnosis
Diagnostic evaluation must be performed after patients have been adequately resuscitated. If an upper GI source is suspected, an
History
The history in these patients should focus on factors that could be associated with potential causes: blood coating the stool suggests hemorrhoidal bleeding while blood mixed in the stool implies a more proximal source; bloody diarrhea and tenesmus is associated with
Physical findings
Orthostatic hypotension implies at least a 15% loss of blood volume and suggests a more severe bleeding episode. Evaluate for abdominal tenderness, masses, and enlargement of the liver and spleen. Additional key elements include a careful and thorough inspection of the anus, palpation for rectal masses, characterization of the stool color, and a stool guaiac card test to evaluate for the presence of blood.[citation needed]
Laboratory findings
Among the blood tests that should be performed are a
Anoscopy
Anoscopy is useful only for diagnosing bleeding sources from the anorectal junction and anal canal, including internal
Flexible sigmoidoscopy
Colonoscopy
Colonoscopy is the test of choice in the majority of patients with acute Lower GI bleeding as it can be both diagnostic and therapeutic. The diagnostic accuracy of colonoscopy in lower GI bleeding ranges from 48% to 90%, and urgent colonoscopy appears to increase diagnostic yield. This wide range in yield is partially explained by different criteria for diagnosis, as often if no active bleeding, nonbleeding visible vessel, or adherent clot is found, bleeding is attributed to a lesion if blood is present in the area. The presence of fresh blood in the
Management
In most cases requiring emergency hospital admission, the bleeding will resolve spontaneously.[2][10] If a patient is suspected of having severe blood loss they will most likely be placed on a vital sign monitor and administered oxygen either by nasal cannula or simple face mask. An intravenous catheter will be placed into an easily accessible area and IV fluids will be administered to replace lost blood volume.[1] Endoscopic evaluation with a colonoscopy (and possibly an esophagogastroduodenoscopy to exclude an UGIB) should typically occur within 24 hours of hospital presentation.[2]
If the person with LGIB is on low-dose
Predicting which patients will develop adverse outcomes, complications or severe bleeding can be difficult. One recent study identified poor kidney function (creatinine > 150 μm), age over 60 years, abnormal haemodynamic parameters on presentation (low blood pressure) and persistent bleeding within the first 24 hours as risk factors for worse outcome.[10]
Surgical intervention is warranted in cases of LGIB that persist despite attempts to stop the bleeding with endoscopic or interventional radiology interventions.[2] It is most likely that a surgical consult will be ordered if the patient is unable to be stabilized by non-invasive techniques, or if a perforation is found that requires surgery (e.g., subtotal removal of the colon).[1]
References
External links
- Oakland, K; Chadwick, G; East, JE; Guy, R; Humphries, A; Jairath, V; McPherson, S; Metzner, M; Morris, AJ; Murphy, MF; Tham, T; Uberoi, R; Veitch, AM; Wheeler, J; Regan, C; Hoare, J (May 2019). "Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology". Gut. 68 (5): 776–789. PMID 30792244.