Lower Gastrointestinal Bleeding: Surgical Perspective

Author: Burt Cagir, MD, FACS, Assistant Professor of Surgery, State University of New York, Upstate
Medical Center; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program
Director, Department of Surgery, Guthrie Clinic
Coauthor(s): Elizabeth Cirincione, MD, Director of Colon and Rectal Surgery, Department of Surgery,
Nassau University Medical Center
Contributor Information and Disclosures
Updated: Sep 4, 2008

Introduction

Acute lower gastrointestinal (GI) hemorrhage accounts for approximately 20% of all cases of GI
hemorrhage. The annual incidence is about 20-27 cases per 100,000 population in westernized
countries. Lower GI hemorrhage continues to be a frequent cause of hospital admission and is a
factor in hospital morbidity and mortality. Mortality rates are reportedly 10-20% and are dependent
on age (>60 y), multiorgan system disease, transfusion requirements in excess of 5 units, need for
operation, and recent stress (eg, surgery, trauma, sepsis). Localization of hemorrhage relative to
the Treitz ligamentum directs the initial evaluation and resuscitation. The passage of maroon
stools or bright red blood from the rectum is usually indicative of massive lower GI hemorrhage.
Lower GI hemorrhage can be due to numerous conditions, including diverticulosis, anorectal
.diseases, carcinomas, inflammatory bowel disease (IBD), and angiodysplasias

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine
Center. Also, see eMedicine's patient education articles, Gastrointestinal Bleeding, Rectal
.Bleeding, Inflammatory Bowel Disease, Diverticulosis and Diverticulitis, and Anal Abscess

History of the Procedure

Understanding of the pathogenesis, diagnosis, and treatment of lower GI bleeding has drastically
changed during the last 50 years. In the first half of the 20th century, large intestinal neoplasms
were believed to be the most common cause of lower GI bleeding. In the 1950s, lower GI
hemorrhage was commonly attributed to diverticulosis. In this period, surgical treatment consisted
of blind segmental bowel resections, with disappointing results. Patients who underwent blind
segmental bowel resection suffered from a prohibitively high rebleeding rate (up to 75%), morbidity
.((up to 83%), and mortality (up to 60%

In the last 4 decades, diagnostic methods for locating the precise bleeding point greatly improved.
In 1965, Baum et al described selective mesenteric angiography, which permitted the identification
of vascular abnormalities and the precise bleeding point.1 Experience with mesenteric angiography
in the late 1960s and 1970s suggested that angiodysplasias and diverticulosis were the most
common reasons for lower GI bleeding. Since its discovery, mesenteric angiography remains the
.criterion standard in precise localization of the bleeding

Rösch et al described superselective visceral arteriography for infusion of vasoconstrictors in 1971

and superselective embolization of the mesenteric vessels as an alternative technique to treat
massive lower GI bleeding in 1972.2, 3 The most feared complication of embolization of the
.mesenteric vessels is ischemic colitis, which has limited its use for GI bleeding

The initial experience with vasopressin infusion was reported in 1973-1974. Vasopressin causes
vasoconstriction and arrests the bleeding in 36-100% of patients. The recurrence rate following
completion of vasopressin infusion can be as high as 71%; therefore, vasopressin is used to
.temporize the acute event and to stabilize patients before surgery

The flexible endoscope was developed in 1954. The full-length colonoscope was developed in
1965 in Japan. The first anal colonoscopy was performed in 1969. Endoscopic control of bleeding
with thermal modalities or sclerosing agents has been in use since the 1980s. One of the
advantages of upper (or lower) endoscopic evaluation is that it provides a means to administer
 therapy in patients with GI bleeding. Nuclear scintigraphy has been used since the early 1980s as
a very sensitive diagnostic tool to evaluate bleeding from GI tract. Nuclear scintigraphy can detect
.hemorrhage at rates as low as 0.1 mL/min

The average age of patients with lower GI bleeding is 60 years in most series. Etiology varies
according to the age of the patient. Segmental bowel resection following precise localization of the
bleeding point is a well-accepted surgical practice today. Despite improvement in diagnostic
imaging and procedures, 10-20% of patients with lower GI bleeding have no demonstrable
bleeding source. Subtotal colectomy is the procedure of choice in patients who are actively
.bleeding from an unknown source

Problem
Lower GI hemorrhage is defined as an abnormal intraluminal blood loss from a source distal to the
Treitz ligamentum. Lower GI bleeding is classified under 3 groups according to the amount of
bleeding (see Media file 1). Massive hemorrhage is a life-threatening condition and requires
.transfusion of at least 5 units of blood

Patients with massive hemorrhage present with a systolic blood pressure of less than 90 mm Hg
and a hemoglobin level of 6 g/dL or less. These patients are usually aged 65 years and older, have
multiple medical problems, and are at risk of death from acute hemorrhage or its complications.
Therefore, the overall mortality rate for massive lower GI hemorrhage ranges from 0-21%. Occult
bleeding manifests as microcytic hypochromic anemia and intermittent guaiac reaction (see Media
.(file 1

Definition of massive lower GI bleeding•

Passage of a large volume of red or maroon blood through the rectum○
Hemodynamic instability and shock○
Initial decrease in hematocrit (Hct) level of 6 g/dL or less○
Transfusion of at least 2 units of packed RBCs○
Bleeding that continues for 3 days○
Significant rebleeding in 1 week○

Frequency
The incidence of lower GI bleeding is essentially unknown. No population-based data on the
incidence of this disorder are available in the United States. Although lower GI bleeding is
common, most patients do not require hospital admission. Patients with significant lower GI
.bleeding are estimated to comprise less than 1% of all hospital admissions in the United States

Two population-based studies are identified in the medical literature. Vernava et al reviewed
Department of Veterans Affairs' (VA) databases for a 4-year period to study the incidence and
etiology of lower GI bleeding.4 They found that less than 1% of 5.1 million hospital admissions
were for lower GI hemorrhage. The other study was a review of the Kaiser Permanente database,
which estimated an annual incidence rate of 20.5 patients per 100,000 (24.2 in males vs 17.2 in
females). The rate of lower GI bleeding increased more than 200-fold from the third to the ninth
.decades of life

.See related CME at Gastrointestinal Bleeding in the Elderly

Etiology
Bleeding from diverticular disease has been reported as the most common reason for massive
lower GI bleeding in most of the single-institution publications. However, the reported frequency of
various other etiologies of lower GI bleeding is not consistent in these manuscripts because of the
 small number of cases and the highly selective referral pattern and patient populations.
Comprehensive knowledge of the etiology of lower GI bleeding is essential for patient
.management and, ultimately, for patient outcome

Vernava and colleagues' review also found that patients with lower GI bleeding comprised only
0.7% of all hospital admissions (17,941 patients).4 The average age of these patients was 64
years. Only 24% of these patients (4410) had a diagnostic workup, including colonoscopy, barium
enema, and/or mesenteric angiography. Among the patients who underwent a diagnostic workup,
the most common causes of bleeding were diverticular disease (60%), IBD (13%), and anorectal
diseases (11%) (see Table 1). Although some publications have reported arteriovenous
malformations as a common cause of lower GI bleeding, the true incidence of arteriovenous
malformations is insignificant (3%), as stated by Vernava et al.4

*Table 1: Common Causes of Lower GI Bleeding in Adults

Open table in new window

[ CLOSE WINDOW ]

Table

LOWER GI HEMORRHAGE IN ADULTS PERCENTAGE OF PATIENTS

Diverticular disease 60%

Diverticulosis/diverticulitis of small intestine-
Diverticulosis/diverticulitis of colon-

IBD 13%
Crohn's disease of small bowel, colon, or both-
Ulcerative colitis-
Noninfectious gastroenteritis and colitis-

Benign anorectal diseases 11%

Hemorrhoids-
Anal fissure-
Fistula-in-ano-

Neoplasia 9%
Malignant neoplasia of small intestine-
Malignant neoplasia of colon, rectum, and anus-

Coagulopathy 4%

(Arteriovenous malformations (AVM 3%

TOTAL 100%

LOWER GI HEMORRHAGE IN ADULTS PERCENTAGE OF PATIENTS

Diverticular disease 60%

Diverticulosis/diverticulitis of small intestine-
Diverticulosis/diverticulitis of colon-

IBD 13%
Crohn's disease of small bowel, colon, or both-
Ulcerative colitis-
Noninfectious gastroenteritis and colitis-

Benign anorectal diseases 11%

Hemorrhoids-
 Anal fissure-
Fistula-in-ano-

Neoplasia 9%
Malignant neoplasia of small intestine-
Malignant neoplasia of colon, rectum, and anus-

Coagulopathy 4%

(Arteriovenous malformations (AVM 3%

TOTAL 100%

From Vernava and colleagues' survey of 4410 patients4*

Longstreth reviewed the discharge summary and colonoscopy data from a large health
maintenance organization with members in the San Diego, Calif, area.5 In all, 235 hospital
admissions for 219 patients were reviewed. The estimated hospital admission rate for lower GI
bleeding was found to be 20 patients per 100,000 admissions. Bleeding from diverticular disease
was the most common reason for lower GI bleeding (42%), followed by colorectal malignancies
(9%) and ischemic colitis (8.7%). The incidence of lower GI bleeding due to colonic
angiodysplasias was 6%. These findings were consistent with those of the VA database study,
.although that study was limited to males

The common causes of lower GI bleeding in infants, children, and adolescents differ from those
found in adults. Meckel diverticulum, intussusception, polyposis syndromes, and IBD are the
.(common causes of GI bleeding in children and adolescents (see Table 2

Table 2: Common Causes of Lower GI Hemorrhage in Children and Adolescents

Open table in new window

[ CLOSE WINDOW ]

Table

LOWER GI HEMORRHAGE IN CHILDREN & ADOLESCENTS

Intussusception

Polyps and polyposis syndromes

Juvenile polyps and polyposis-
Peutz-Jeghers syndrome-
(Familial adenomatous polyposis (FAP-

IBD
Crohn's disease-
Ulcerative colitis-
Indeterminate colitis-

Meckel diverticulum

LOWER GI HEMORRHAGE IN CHILDREN & ADOLESCENTS

Intussusception

Polyps and polyposis syndromes

Juvenile polyps and polyposis-
Peutz-Jeghers syndrome-
(Familial adenomatous polyposis (FAP-
 IBD
Crohn's disease-
Ulcerative colitis-
Indeterminate colitis-

Meckel diverticulum

Many other causes of lower GI bleeding have been documented, including hemorrhage from small
bowel diverticulosis, Dieulafoy lesions of the colon or small bowel, portal colopathy with colonic
and rectal varices, endometriosis, solitary rectal ulcer syndrome, and vasculitides with small bowel
.(or colonic ulcerations (see Rare causes of lower GI bleeding

Pathophysiology
Diverticulosis is a common acquired condition in Western societies. Approximately 50% of adults
older than 60 years have radiologic evidence of diverticulosis. Diverticula are most commonly
located in the sigmoid and descending colon. Diverticular bleeding originates from vasa rectae
located in submucosa, which can rupture at the dome or the neck of the diverticulum. Up to 20% of
patients with diverticular disease experience bleeding. In 5% of patients, bleeding from diverticular
disease can be massive. Hemorrhage from diverticular disease stops spontaneously in 80% of
patients. Although diverticulosis is a left colonic condition, approximately 50% of diverticular
bleeding originates from a diverticulum located proximal to the splenic flexure. Diverticula located
on the right side may expose the larger portions of vasa rectae to injury because they have wider
.necks and larger domes compared to the typical left-sided colonic diverticulum

Colonic angiodysplasias are arteriovenous malformations located in the cecum and ascending
colon. Colonic angiodysplasias are an acquired lesion affecting elderly persons older than 60
years. These lesions are composed of clusters of dilated vessels, mostly veins, in the colonic
mucosa and submucosa. Colonic angiodysplasias are believed to occur as a result of chronic,
intermittent, low-grade obstruction of submucosal veins as they penetrate the muscular layer of the
colon. The characteristic angiographic findings are clusters of small arteries during the arterial
phase of the study, accumulation of contrast media in vascular tufts, early opacification, and
persistent opacification due to the late emptying of the draining veins. If mesenteric angiography is
.performed at the time of active bleeding, extravasation of contrast media is visualized

Unlike diverticular bleeding, angiodysplasia tends to cause slow but repeated episodes of
bleeding. Therefore, patients with angiodysplasia present with anemia and syncopal episodes.
Infrequently, angiodysplasias can cause an abrupt loss of large quantities of blood.
Angiodysplasias can be easily recognized by colonoscopy as 1.5- to 2-mm red patches in the
mucosa. Actively bleeding lesions can be treated with colonoscopic electrocoagulation. Incidentally
.discovered lesions should be left alone

Massive hemorrhage due to IBD is rare. Ulcerative colitis causes bloody diarrhea in most cases. In
up to 50% of patients with ulcerative colitis, mild-to-moderate lower GI bleeding occurs, and
.approximately 4% of patients with ulcerative colitis have massive hemorrhage

Lower GI bleeding in patients with Crohn's disease is not as common as in patients with ulcerative
colitis; 1-2% of patients with Crohn's disease may experience massive bleeding. The frequency of
bleeding in patients with Crohn's disease is significantly more common with colonic involvement
.than with small bowel involvement alone

Ischemic colitis, the most common form of ischemic injury to the digestive system, frequently
involves the watershed areas, including the splenic flexure and the rectosigmoid junction. In most
cases, the precipitating event cannot be identified. Colonic ischemia is a disease of the elderly
population and is commonly observed after patients' sixth decade of life. Ischemia causes mucosal
and partial-thickness colonic wall sloughing, edema, and bleeding. Ischemic colitis is not
 associated with significant blood loss or hematochezia, although abdominal pain and bloody
.diarrhea are the main clinical manifestations

Colorectal adenocarcinoma is the third most common cancer in the United States. Colorectal
carcinoma causes occult bleeding, and patients usually present with anemia and syncopal
episode. The incidence of massive bleeding due to colorectal carcinoma varies from 5-20% in
different series. Postpolypectomy hemorrhage is reported to occur up to 1 month following
colonoscopic resection. The reported incidence is between 0.2-3%. Postpolypectomy hemorrhage
can be managed by electrocoagulation of the polypectomy site/bleeding with either snare or hot
.biopsy forceps or by epinephrine injection

Benign anorectal disease (eg, hemorrhoids, anal fissures, anorectal fistulas) can cause intermittent
rectal bleeding. Massive rectal bleeding due to benign anorectal disease has also been reported.
The VA database review revealed that 11% of patients with lower GI bleeding had hemorrhage
from anorectal disease. Patients who have rectal varices with portal hypertension may develop
painless massive lower GI bleeding; therefore, examining the anorectum early in the workup is
important. If active bleeding is identified, treat it aggressively. Note that the discovery of benign
anorectal disease does not exclude the possibility of more proximal bleeding from the lower GI
.tract
Presentation
Massive lower GI bleeding is a life-threatening condition. Although massive lower GI bleeding
manifests as maroon stools or bright red blood from the rectum, patients with massive upper GI
bleeding may also present with similar findings. Regardless of the level of the bleeding, one of the
most important elements of the management of patients with massive upper or lower GI bleeding
is the initial resuscitation. These patients should receive 2 large-bore intravenous catheters and
isotonic crystalloid infusions. Meanwhile, rapid assessment of vital signs, including heart rate,
systolic blood pressure, pulse pressure, and urine output, should be performed. Orthostatic
hypotension (ie, a blood pressure fall of >10 mm Hg) is usually indicative of blood loss of more
.than 1000 mL

History and physical examination are essential parts of an initial evaluation. Document prior
episodes of GI bleeding as well as significant medical history and prior medications, including
peptic ulcer disease, liver disease, cirrhosis, coagulopathy, IBDs, and use of nonsteroidal anti-
inflammatory drugs (NSAIDs) and/or warfarin. Symptoms are also important in identifying the
source of bleeding. The symptoms of young patients with abdominal pain, rectal bleeding,
diarrhea, and mucous discharge may be associated with IBD. On the other hand, symptoms of
elderly patients with abdominal pain, rectal bleeding, and diarrhea can be associated with ischemic
colitis. Stools streaked with blood, perianal pain, and blood drops on the toilet paper or in the toilet
.bowl may be associated with perianal pathology, such as anal fissure or hemorrhoidal bleeding

The physical examination must include careful inspection and examination of the oropharynx,
nasopharynx, abdomen, perineum, and anal canal. Nasogastric aspirates usually correlate well
with upper gastric hemorrhage proximal to the Treitz ligamentum; therefore, insert a nasogastric
tube to confirm the presence or absence of blood in the stomach. If necessary, perform gastric
lavage with warm isotonic fluids to obtain bilious discharge from the nasogastric tube to exclude
.any upper GI bleeding beyond the pylorus

Nasogastric tube aspirates can provide false-negative results in approximately 50% of cases if the
aspirate contains no bile or if the bleeding is intermittent. These patients eventually need
esophagogastroduodenoscopy (EGD) to obtain a more specific evaluation of the upper GI tract.
Place a Foley catheter to monitor urine output. Careful digital rectal examination, anoscopy, and
.rigid proctosigmoidoscopy should exclude an anorectal source of bleeding
Indications
Surgical treatment is indicated if the patient continues to bleed and if nonoperative management is
unsuccessful or unavailable. Segmental colectomy is indicated if the bleeding point is localized by
preoperative diagnostic studies. Subtotal colectomy is the procedure of choice if the bleeding point
cannot be localized with preoperative or intraoperative diagnostic studies. Subtotal colectomy is
associated with negligibly higher perioperative morbidity and mortality compared to segmental
colonic resection. In addition, postoperative diarrhea can be a significant problem in elderly
.patients who undergo subtotal colectomy and ileorectal anastomosis

Relevant Anatomy

The average length of the large intestine is 135-150 cm. Ascending and descending segments of
the colon are fixed to the retroperitoneum. On the other hand, the transverse and sigmoid colon
are supported by a mesentery in the abdomen. A comprehensive understanding of small bowel
and colonic vascular anatomy is essential for any surgeon performing primary lower GI surgery for
.hemorrhage or other diseases

The ileocolic, right colic, and middle colic branches of the superior mesenteric artery supply blood
to the cecum, ascending, and proximal transverse colon, respectively. The superior mesenteric
vein drains the right side of the colon, joining the splenic vein to form the portal vein. The inferior
mesenteric artery supplies blood to the distal transverse, descending, and sigmoid colon. The
inferior mesenteric vein carries blood from the left side of the colon to the splenic vein. A rich
network of vessels from the superior, middle, and inferior hemorrhoidal vessels supplies the
.rectosigmoid junction and rectum

Contraindications

No contraindications exist with regard to surgery in hemodynamically unstable patients with active
bleeding. Surgery is warranted even in the absence of accurate preoperative localization for
patients who require transfusion of 5 units or more blood in the first 24 hours. Surgery is also
.necessary in patients with recurrent bleeding during the same hospitalization

Workup

Laboratory Studies
Appropriate blood tests include CBC; serum electrolytes (sequential multiple analysis 7•
[SMA7]); and coagulation profile, including activated partial thromboplastin time (aPTT),
.prothrombin time (PT), manual platelet count, and bleeding time
Imaging Studies
The role of nuclear scintigraphic imaging in the diagnosis and treatment of patients who•
present with lower GI bleeding remains controversial. Nuclear scintigraphy is a sensitive
diagnostic tool (86%) and can detect hemorrhage at rates as low as 0.1 mL/min. Nuclear
scintigraphy is reportedly 10 times more sensitive than mesenteric angiography in
detecting ongoing bleeding. The scintigraphic imaging suffers from a low specificity (50%)
due to its limited resolution; this has led many investigators to recommend that
scintigraphic imaging be used primarily as a screening examination to select patients for
.mesenteric angiography
No preparation is required for99m sulfur colloid. This agent has a very short half-life (2.5-3.5•
min) because it is rapidly cleared by the reticuloendothelial system. Because it enhances
the liver and spleen, bleeding from both the hepatic flexures and the splenic flexures may
be obscured.99m Tc-labeled RBC scintigraphy is the preferred technique because its half-
.life is longer. Images delayed up to 24 hours can be taken with labeled RBC scanning
 The sensitivity of the99m Tc-labeled RBC scintigraphy is reportedly 20-95%. The bleeding•
site can be identified accurately when intraluminal accumulation of99m Tc-labeled RBCs is
observed during the dynamic phase of scanning. Although nuclear scintigraphy is
sensitive enough to diagnose ongoing bleeding at a rate as low as 0.1 mL/min, it is not
highly accurate in locating the bleeding point. The bleeding point is accurately localized in
52-90% of positive cases, with an average of 86% and incorrect localization of 14%, as
reported in 24 publications. Because of the high false localization rate (10-60%) for the
bleeding site, performing segmental resections based solely on scintigraphy results is not
.recommended
Ng and colleagues reviewed 86 patients with positive99m Tc-labeled RBC scintigraphy•
findings.3 Patients with an immediate blush (within 2 min of the study) revealed a positive
predictive value of 75% for angiography. Patients with a delayed blush (after 2 min of the
study) had a negative predictive value of 93% for angiography. Thus, patients with
delayed blush should proceed with colonoscopic evaluation instead of mesenteric
angiography. Use99m Tc-labeled RBC scintigraphy as a prescreening test for selective
.mesenteric angiography
In 1992, Ryan et al published their experience with99m Tc-labeled RBC scintigraphy.7 In this•
study, 29 patients with lower GI bleeding were identified. Scintigraphy identified the site of
bleeding accurately in 9 patients with massive lower GI bleeding. In 6 of 9 patients, the
scintigraphy finding was positive in the first 5 minutes of the study. In 3 patients, the
.scintigraphy finding was positive at 14-45 minutes
Another study was performed to evaluate the efficacy of RBC scintigraphy in○
confirming the location of the lower GI bleeding. Twenty-one patients with positive
scintigraphy results were included in the study. Of these, the bleeding site was
confirmed in 16 patients by various methods. RBC scintigraphy findings were
positive within the continuous phase of the study in 10 of the confirmed studies
and in none of the incorrectly localized studies. Therefore, in carefully selected
cases, patients can undergo segmental resections only if scintigraphy findings
.are strongly positive in the very initial part of the test
Cinematic99m Tc-labeled RBC scintigraphy (real-time scanning) has been○
described as a noninvasive alternative to mesenteric angiography. Continuous
dynamic imaging using sequential computer acquisition provides more accurate
localization of the bleeding point because it enables cinematic playback. More
studies are necessary to identify the success of real-time scintigraphic
.evaluations
Recurrent lower GI bleeding occurs after negative99m Tc-labeled RBC○
scintigraphy. Hammond et al conducted retrospective evaluations of 84 patients
with negative99m Tc-labeled RBC scintigraphy.8 The overall rebleeding rate was
found to be 27% (n=23 patients). Hammond et al concluded that age, gender,
bleeding source, use of anticoagulant/antiplatelet agents, length of hospital stay,
admission Hct, Hct nadir, and transfusion requirements are not predictive of the
patients who will rebleed.8
The use of111 indium–labeled RBC scintigraphy to detect intermittent bleeding has been•
.described in the medical literature in a handful of publications
Ferrant and colleagues initially used111 indium–labeled RBC scintigraphy in○
patients with lower GI bleeding in 1980; however, it remains underutilized
because of a prolonged half-life of 67 hours.9 This scintigraphy is more expensive
and also is a more labor-intensive technology than99m Tc labeling. The image
quality and localization of bleeding can be less than desirable because of the
prolonged half-life and intestinal motility. However, the longer half-life of111
 indium–labeled RBC scintigraphy can be useful in locating intermittent bleeding
.points, particularly when conventional methods have failed
Schmidt et al published a report on 6 patients in whom99m Tc scanning was initially○
unrewarding.6 Subsequent scintigraphy with111 indium–labeled RBCs located the
.site of bleeding in all patients
Mole et al detected synchronous, small and large intestinal adenocarcinomas○
with111 indium–labeled RBC scintigraphy in a 70-year-old patient with intermittent
GI bleeding and profound blood loss anemia.7
In 1965, Baum et al described selective mesenteric angiography in the diagnosis of GI•
bleeding.1 Since then, the value of mesenteric angiography in the diagnosis and
management of lower GI bleeding has been well established. The extravasation of
contrast material indicates a positive study finding. Selective mesenteric angiography can
detect bleeding at a rate of more than 0.5 mL/min. In a patient with active GI bleeding, the
radiologist concentrates on the major mesenteric vessel most likely to be responsible (eg,
the inferior mesenteric artery in bright red rectal bleeding). If no bleeding is identified, the
other major mesenteric vessels, including the superior mesenteric artery and celiac axis,
are studied. In some cases, aberrant vascular anatomy can contribute to colonic or small
bowel circulation; in other cases, patients with upper GI bleeding may present in an
.uncommon clinical fashion
Helical CT scan of the abdomen and pelvis can also be used when routine workup fails to•
determine the cause of active GI bleeding. Multiple criteria, including vascular
extravasation of the contrast medium, contrast enhancement of the bowel wall, thickening
of the bowel wall, spontaneous hyperdensity of the peribowel fat, and vascular dilatations,
are used to establish the bleeding site with helical CT. The presence of diverticula alone
was not enough to define the bleeding site. Three-phase helical CT should be performed
using intravenous contrast. Water can be used as an oral contrast in the workup of
patients who are actively bleeding. Therefore, helical CT could be a good diagnostic tool
.in acute lower GI bleeding to help the physician identify the bleeding site
A pilot study was done in Sydney, Australia, to evaluate CT as a diagnostic tool for acute•
.lower GI bleeding
Helical CT was compared to selective mesenteric angiography and colonoscopy○
in the diagnosis and detection of a bleeding site. Seven patients with acute lower
GI bleeding were included. All patients underwent mesenteric angiography
following CT. Colonoscopies were also performed on 5 patients investigated with
both CT and mesenteric angiography. Both modalities had concordant findings of
2 active bleeding sites, 1 nonbleeding rectal tumor, and 1 negative result. In 3
patients, the source of bleeding was found on CT, whereas the mesenteric
angiography finding was negative. Colonoscopies performed in these 3 patients
.confirmed blood in the colon/ileum
Sabharwal et al concluded that helical CT is a safe, convenient, and accurate○
diagnostic tool for acute lower GI hemorrhage.12 The authors proposed a new
management algorithm for acute lower GI hemorrhage using CT as the
.preselective mesenteric angiography screening tool
Once the bleeding point is identified, angiography offers potential treatment options, such•
as selective vasopressin drip and embolization. Thirteen publications reported
experiences with selective mesenteric angiography. When 657 patients underwent
mesenteric angiography, the percentage of positive study findings fluctuated between 27-
86%, with an average of 45%. Because of the intermittent nature of lower GI bleeding, the
.number of positive study findings is significantly less with this invasive diagnostic modality
 Emergency angiography as an initial study is indicated in a highly selected group of•
patients with massive ongoing lower GI bleeding. Browder et al used 2 criteria to triage
patients for emergency angiography.13 The criteria were at least 4 units of blood
transfusion in the first 2 hours following hospital admission and systolic blood pressure of
less than 100 mm Hg with aggressive resuscitation. Fifty patients underwent emergency
angiography, and bleeding was localized in 72% of patients. Vasopressin infusion was
successful in 91%; however, half experienced bleeding following cessation of the
vasopressin infusion. Thus, patients with ongoing hemorrhage, emergency angiography,
.and vasopressin infusion have improved operative morbidity, mortality, and outcome
Five to 10% of patients may present with recurrent episodes of massive lower GI bleeding•
without any diagnosis of the bleeding site. These patients experience multiple hospital
admissions; they also undergo recurrent blood transfusions and several invasive studies
repeatedly. Ryan et al performed 17 elective provocative bleeding studies for occult lower
GI bleeding in 16 patients.14 Although an abnormality was identified in 50% of patients,
bleeding was provoked in 6 (37.5%) patients. Most of the positively provoked patients (ie,
5 patients) had a previously positive tagged red cell scintigraphy.14 Of the 6 patients with
provoked bleeding, 3 were treated with superselective embolization at the time of
provoked bleeding, 2 were treated with estrogen therapy, and 1 was treated with palliative
therapy.14 Ten patients did not bleed during the provoked study.14
Widlus and Salis reported 9 patients who underwent provocative angiography with•
Reteplase, a new fibrinolytic agent.15 An initial diagnostic visceral arteriogram was
performed and failed to identify the source of bleeding in each patient.15 Reteplase was
administered, and provocative arteriography was repeated. Bleeding was identified in 8
(89%) patients, and these patients were treated with microembolization, segmental
resection, or conservatively.15 It was concluded that the use of Reteplase is safe and
effective as a provocative agent, stimulating bleeding to allow localization, in patients with
occult, recurrent, massive lower GI bleeding.15
Other Tests
Double-contrast barium enema examinations can be justified only for elective evaluation•
of unexplained lower GI bleeding. Do not use barium enema examination in the acute
hemorrhage phase because it makes subsequent diagnostic evaluations, including
.angiography and colonoscopy, impossible
Elective contrast radiography of the small bowel and/or enteroclysis is often valuable in•
.investigation of long-term, unexplained lower GI bleeding
Diagnostic Procedures
Colonoscopy has an important role in the diagnosis and treatment of lower GI bleeding.•
Rapid colonic lavage with GoLYTELY clears the intraluminal blood, clot, and stool,
providing an adequate environment for visualization of the lower GI mucosa and lesions.
GoLYTELY can be administered orally or by nasogastric tube. The best candidates for
colonoscopic evaluation are patients who are bleeding slowly or who have already
.stopped bleeding
Histologic Findings
Most colonic diverticula are false pulsion diverticula and are composed only of mucosa and
submucosa herniated through the colonic wall musculature. Hemorrhage associated with
.diverticula comes from perforated vasa rectae located at the neck or the apex of the diverticula

Colonic angiodysplasias are vascular ectasias commonly located on the right side of the colon.
Microscopically, vascular ectasia consists of dilated thin-walled venules and capillaries localized in
.the submucosa of the colonic wall
 Treatment

Medical Therapy
Vasoconstrictive agents

Initially, vasoconstrictive agents, such as vasopressin (Pitressin), can be used. An experimental

study of treatment of lower GI bleeding by selective arterial infusion of vasoconstrictors, such as
epinephrine with propranolol and vasopressin, was reported. Although epinephrine and propranolol
drastically reduced mesenteric blood flow, they also caused a rebound increase in blood flow and
recurrent bleeding. Vasopressin is a pituitary hormone that causes severe vasoconstriction in the
splanchnic bed. Vasoconstriction reduces the blood flow and facilitates hemostatic plug formation
in the bleeding vessel. The results are less than satisfactory in patients with severe atherosclerosis
.and coagulopathy

Following positive angiogram findings, the angiographic catheter is left in place and vasopressin
infusion is started at a rate of 0.2 unit/min. A repeat angiogram is obtained every half hour, and the
rate of infusion is increased up to 0.4 unit/min if bleeding continues. Vasopressin doses above 0.4
unit/min are not recommended because of the high rate of potential complications. If hemorrhage
remains controlled, the dose of vasopressin is reduced to half every 6-12 hours. The angiographic
catheter, following an additional 6-12 hours of saline infusion, is removed. If vasopressin infusion
.fails to control the hemorrhage, patients should undergo a segmental resection

The initial experience with vasopressin infusion was reported in 1973-1974. Twenty-four patients
were included in this study. In 22 of the patients, bleeding was controlled. Of these, 12 received no
further therapy and were discharged. Three patients (25%) developed recurrent bleeding within 2-
12 months of discharge. Selective vasopressin infusion was used as the sole treatment and
arrested the bleeding in 36-100% of the cases. Because the rebleeding rates fluctuated between
.27-71%, vasopressin infusion was used in the acute event to stabilize patients prior to surgery

During vasopressin infusion, monitor patients for recurrent hemorrhage, myocardial ischemia,
arrhythmias, hypertension, and volume overload with hyponatremia. Nitroglycerine paste or drip
can be used to overcome cardiac complications. Selective mesenteric infusion induces bowel wall
contraction and spasms, which should not be confused with bowel wall ischemia. Do not
administer vasopressin into systemic circulation intravenously because this causes coronary
.vasoconstriction, diminished cardiac output, and tachyphylaxis

Superselective embolization

Superselective embolization of the mesenteric vessels is an alternative technique for treating

massive lower GI bleeding. Rösch and colleagues first described this technique in 1972.
Autologous clot, Gelfoam, polyvinyl alcohol, microcoils, ethanolamine, and oxidized cellulose can
be used as embolic agents. Embolization involves superselective catheterization of the bleeding
.vessel to minimize necrosis, the most feared complication of ischemic colitis

Rosenkrantz et al reported 3 cases of colonic infarction.16 One patient died following segmental
colectomy, and the other patients revealed full-thickness bowel wall injury in the resected
specimen. Intestinal ischemia and infarction have also been reported. To prevent this complication,
perform embolization beyond the marginal artery as close as possible to the bleeding point in the
terminal mural arteries. A total of 139 cases have been collected from the medical literature since
.1972

Overall bleeding was controlled in 115 patients (83%), with a rebleeding rate of 11% (15 patients).
Complications were observed in 20%, and bowel injury and perforation were observed in 12% (16
patients). The overall mortality rate was 11% (15 patients); thus, careful patient selection is
 necessary for this procedure. Use embolization in high-risk patients whose conditions are
refractory to conservative management. If terminal mural branches of the bleeding vessel cannot
.be catheterized, abort the procedure and immediately perform surgery

Kuo et al evaluated the safety and effectiveness of superselective microcoil embolization for the
treatment of lower GI bleeding in 2003.17 Twenty-two patients with angiographic evidence of lower
GI bleeding underwent superselective microcoil embolization during a 10-year period. Complete
clinical success was achieved in 86% of patients with a rebleeding rate of 14%.17 Minor and major
ischemic complication rates were reported as 4.5% and 0%, respectively.17

The authors also reviewed the data from 122 cases of lower GI superselective microcoil
embolization in the literature. The meta-analysis was performed in 144 patients. This combined
analysis revealed a minor ischemic complication rate of 9% and a major ischemic complication
rate of 0%. It was concluded that superselective microcoil embolization is a safe and effective
treatment of acute lower GI hemorrhage.17

Colonoscopy

Colonoscopy has become the first choice of diagnostic modality following rapid purge with volume
cathartics, such as GoLYTELY. Jensen and Machicado have evaluated the role of urgent
colonoscopy after purge prospectively in 80 consecutive patients with severe hematochezia.18
Urgent colonoscopies were performed in the intensive care unit. Seventy-four percent of patients
had colonic lesions, 11% had upper GI lesions, and 9% had presumed small bowel lesions; in 6%,
no bleeding site was identified.18 Although Jensen and Machicado recommended that EGD be
.performed prior to colonoscopy,18 upper and lower endoscopies can be performed simultaneously

In another study, colonoscopy yielded a diagnosis in 90% of the patients, which provided
opportunity for therapy at the same time. The patients who underwent colonoscopic evaluation had
a significantly shorter hospital stay. Perform the urgent colonoscopy in the operating room or
endoscopy suite on hemodynamically stable patients. If patients become unstable or colonoscopy
.reveals an active fulminant inflammation, abort the procedure

Endoscopic coagulation

The treatment options for angiodysplasias are numerous, including segmental bowel resection and
selective mesenteric embolization. Endoscopic coagulation of angiodysplasias is becoming a
treatment of choice using either heated probe or lasers, such as Nd:YAG and argon. Argon laser
treatment is recommended for mucosal or superficial lesions because the energy penetrates only 1
.mm. Nd:YAG lasers are more useful for deeper lesions because they penetrate 3-4 mm

Hunter et al evaluated 222 GI endoscopic laser procedures in 122 patients. Hemorrhage was
arrested in 84% of the patients with GI bleeding. No perforations were reported in this series. One
death occurred and was attributed to laser therapy in a patient with duodenal ulcer and
.gastroduodenal artery bleeding

Forty patients with GI arteriovenous malformations underwent 72 photocoagulation sessions with

mostly argon laser. Of those 40 patients, 15 had significant hemorrhage from colonic arteriovenous
malformations. No deaths occurred in ablation of GI arteriovenous malformations in 15 patients
.with colonic lesion

One of the advantages of upper or lower endoscopic evaluation is that it provides access to
therapy in patients with GI bleeding. Endoscopic control of bleeding can be achieved using thermal
modalities or sclerosing agents. Absolute alcohol, morrhuate sodium, and sodium tetradecyl
.sulfate can be used for sclerotherapy of upper and lower GI lesions
 Endoscopic thermal modalities (eg, laser photocoagulation, electrocoagulation, heater probe) can
also be used to arrest hemorrhage. Endoscopic control of hemorrhage is suitable for GI polyps and
cancers, arteriovenous malformations, mucosal lesions, postpolypectomy hemorrhage,
.endometriosis, and colonic and rectal varices

The medical literature has also been reviewed for endoscopic treatment of significant lower GI
bleeding. A total of 286 patients were identified in 8 publications. Hemorrhage was successfully
arrested in 70% of patients, with a rebleeding rate of 15%. Endoscopic therapy for lower GI
.bleeding is a minimally invasive and viable option in carefully selected patients
Surgical Therapy
An emergency operation is required in approximately 10% of patients with lower GI bleeding.
When the bleeding point is localized, perform a limited segmental resection of the small or large
bowel. The crude outcome analysis was applied to 483 cumulative cases of limited segmental
resection derived from 23 publications since 1974. The rebleeding rate was 7% (0-21%), and the
mortality rate was 10% (0-15%). A morbidity rate of 0-33% was reported in only a very few
publications; thus, limited segmental resection is preferred because it can be performed with low
.morbidity, mortality, and rebleeding rates

If the patient is hemodynamically unstable because ongoing hemorrhage, perform an emergency

.operation before any diagnostic study

In these cases, make every attempt to diagnose the bleeding point intraoperatively. Intraoperative
EGD, surgeon-guided enteroscopy, and colonoscopy may be helpful in diagnosing undiagnosed
massive GI bleeding. Depending on the availability of local resources and the patient's condition, it
may sometimes be better to perform subtotal colectomy with distal ileal inspection than to try to
achieve these other tests, particularly if the surgeon is not privileged or comfortable with
.endoscopy

If the bleeding point cannot be diagnosed following a thorough intraoperative endoscopy and
examination and if evidence points to colonic bleeding, perform a subtotal colectomy with ileorectal
anastomosis. Subtotal colectomy is a rational option because it is associated with a very low
.rebleeding rate (3%) and with acceptable average morbidity (32%) and mortality (19%) rates

Practitioners must understand that blind segmental resection should not be performed because of
a prohibitively high rebleeding rate of up to 75%, a morbidity rate up to 83%, and a mortality rate
up to 60%. Once the bleeding point is identified, a limited segmental resection should be
.performed
Patients who have experienced multiple episodes of lower GI bleeding without a known source or
diagnosis should undergo elective mesenteric angiography, upper and lower endoscopy, Meckel
scan, upper GI with small bowel series, and enteroclysis. Elective evaluation of the entire GI tract
.may identify uncommon lesions and undiagnosed arteriovenous malformations

Rare causes of lower GI bleeding•

Chronic radiation enteritis/proctitis○

Ischemic colitis/mesenteric vascular insufficiency○

Small bowel diverticulosis○
Meckel diverticulum○
Colonic/rectal varices○
Portal colopathy○

Solitary rectal ulcer syndrome○

Diversion colitis○
 Dieulafoy lesion of colon○
Dieulafoy lesion of small bowel○
Vasculitides○
Small bowel ulceration○
Intussusception○
Endometriosis○
GI bleeding in runners○

If the bleeding point is diagnosed by mesenteric angiography, vasopressin infusion can be

temporarily used to control the hemorrhage to stabilize the patient in anticipation of semiurgent
segmental bowel resection. Use selective mesenteric embolization in high-risk patients for whom
the operative management is associated with prohibitive risk of morbidity and mortality. If
mesenteric embolization is used, these patients must be carefully monitored for bowel ischemia
and perforation. Any evidence of ongoing bowel ischemia and/or unexplained sepsis following
mesenteric embolization requires exploratory laparotomy to resect the affected bowel segment.
Perform subtotal colectomy with ileoproctostomy in patients with multiple episodes of nonlocalized
.lower GI bleeding or bilateral sources of colonic hemorrhage
Preoperative Details
Acute lower GI hemorrhage is a common clinical entity and is associated with significant morbidity
and mortality. Mortality rates associated with lower GI hemorrhage are reported to be 10-20% and
are dependent on age (>60 y), multiorgan system disease, transfusion requirements (>5 units),
.(need for operation, and recent stress (eg, surgery, trauma, sepsis

Three major aspects are involved in managing lower GI hemorrhage. The initial priority is to treat
the shock. Second, localization of the source of bleeding is required to perform the third task—
formulating an interventional plan. Insert a nasogastric tube in all patients. A clear bile-stained
aspirate generally excludes bleeding proximal to the Treitz ligamentum. After initial resuscitation,
.undertake a search for the cause of the bleeding to precisely locate the bleeding point

Following accurate localization by angiogram, bleeding can be temporarily controlled with either
angiographic embolization or vasopressin infusion. Segmental bowel resection is performed in the
next 24-48 hours following correction of the patient's physiologic parameters, which include
.hypotension, hypothermia, acute hemorrhagic anemia, and deficient coagulation factors
Intraoperative Details
Surgical intervention is required in only a small percentage of patients with lower GI hemorrhage.
The surgical option depends on whether the bleeding source has been accurately identified
.preoperatively; if so, it is then possible to perform segmental intestinal resection

If the bleeding source is unknown, an upper GI endoscopy should be performed prior to any
surgical exploration. At celiotomy, identifying the bleeding point is often impossible, as blood
refluxes into the proximal and distal bowel. The abdominal cavity is explored through a midline
vertical incision. The assistance of a gastroenterologist is required for intraoperative endoscopic
evaluation. The colonoscope is introduced, and the surgeon assists its passage. On-table colonic
lavage and colonoscopy may identify the colonic source of bleeding. Surgeon-guided
intraoperative small bowel enteroscopy is also performed when no colonic source of bleeding is
.identified. Again, the colonoscope can be used for this procedure

Unlike colonoscopy, enteroscopy is performed during the advancement of the scope.

Colonoscopic manipulation of the small bowel may cause iatrogenic mucosal tears and
hematomas, which may be mistakenly identified as a source of bleeding. Another intraoperative
strategy is to clamp segments of the bowel with noncrushing intestinal clamps to identify the
segment that fills with blood. If the bleeding point cannot be diagnosed through intraoperative pan-
 intestinal endoscopy and examination and if evidence points to a colonic bleeding, perform a
.subtotal colectomy with end ileostomy

Postoperative Details
Hypotension and shock are the eventual consequences of blood loss, but this depends on the rate
of bleeding and the patient's response. Clinical development of shock may precipitate myocardial
infarction, cerebrovascular accident, and renal or hepatic failure. Azotemia occurs in patients with
.GI blood loss

Follow-up
Postoperative office visits every 2 weeks are essential to ensure proper wound healing. Upon
discharge, a general diet abundant in fruits and vegetables is recommended. Patients are
.instructed to drink 6-8 glasses of fluid per day. Psyllium seed preparations should also be started

Complications

Patients who have had surgery of the lower GI tract are prone to the development of
complications. The most common early postoperative complications are intra-abdominal or
anastomotic bleeding, ileus, mechanical small bowel obstruction (SBO), intra-abdominal sepsis,
localized or generalized peritonitis, wound infection and/or dehiscence, Clostridium difficile colitis,
pneumonia, urinary retention, urinary tract infection (UTI), deep venous thrombosis (DVT), and
.(pulmonary embolus (PE

Intra-abdominal sepsis following colorectal surgery is a life-threatening complication and requires

aggressive resuscitation. Systemic conditions (eg, severe blood loss and shock, poor bowel
preparation, irradiation, diabetes, malnutrition, hypoalbuminemia) may adversely affect
anastomotic healing. Changes in anatomy and physiology of the large bowel, high bacterial
content, improper operative technique, tension, and ischemia can cause anastomotic leak
associated with abscess and intra-abdominal sepsis. This condition requires either laparotomy (if
.(the sepsis is generalized) or percutaneous drainage (if the sepsis is localized

Delayed complications usually occur more than a week after surgery. The most common delayed
.complications are anastomotic stricture, incisional hernia, and incontinence

Outcome and Prognosis

Identification of the bleeding point is the most important initial step in treatment. Once the bleeding
point is localized, the treatment options are straightforward and curative. Although diagnostic
methods for precisely locating the bleeding point have greatly improved over the last 3 decades,
10-20% of patients with lower GI bleeding have no demonstrable bleeding source. Therefore, this
complex problem requires systematic and orderly evaluation to reduce the percentage of
.undiagnosed and untreated cases of lower GI bleeding

Future and Controversies

The evolution of more sophisticated diagnostic imaging (eg, angiography, bleeding scan, flexible
fiberoptic colonoscope) offers the promise of precise localization of the bleeding site. These
advances also provide nonoperative and less invasive control of bleeding using angiographic
techniques or colonoscope. Pharmacologic discoveries are also improving patient care and
outcome. Therefore, the therapeutic armamentaria have expanded greatly in the last 50
years.Precise localization of the bleeding point is essential for treatment of lower GI bleeding.
Despite the improvement in diagnostic imaging and procedures, up to 10-20% of the patients with
lower GI bleeding have no demonstrable bleeding source; therefore, noninvasive diagnostic
.images and techniques should be developed to improve patient outcome