Lower gastrointestinal bleeding resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]
Definition
Lower GI bleed refers to any bleeding originating from gastrointestinal tract distal to ligament of Treitz.
- Acute GI bleed: Defined as bleeding occurring for less than 3 days.
- Chronic GI bleed: Defined as slow and intermittent bleeding occurring over a duration of several days.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Any severe GI bleed can be life threatening and should be managed appropriately irrespective of the cause.
Common Causes
- Diverticulosis
- Colitis
- Angiodysplasia
- Colon cancer
- Radiation enteritis
- Inflammatory bowel disease
- Anorectal disorders
Management
Shown below is an algorithm summarizing the approach to [[Lower GI bleed]].
Characterize the symptoms ❑ Frank blood per rectum (bleeding from left colon) Obtain past medical history: ❑ Use of NSAIDs, aspirin or anticoagulants ❑ History of radiation ❑ History of liver disease ❑ History of IBD ❑ Recent polypectomy ❑ Family history of colorectal cancer | |||||||||||||||||||||||||||||||||||||
Examine the patient ❑ Assess hemodynamic status | Hematochezia PLUS hemodynamic instability | Nasogastric lavage (to rule out UGIB) | |||||||||||||||||||||||||||||||||||
Order tests ❑ Blood type and cross match ❑ CBC ❑ Coagulation profile ❑ Liver function tests ❑ Electrolytes ❑ BUN ❑ Creatinine ❑ EKG for elderly patients | |||||||||||||||||||||||||||||||||||||
Initiate initial supportive measures ❑ Intravenous access | |||||||||||||||||||||||||||||||||||||
| Risk stratification of patients | |||||||||||||||||||||||||||||||||||||
❑ Young patient ❑ Scant bleeding ❑ No anemia ❑ Suspected bleeding from anorectal region | ❑ Severe active bleeding ❑ Unstable hemodynamically ❑ Need for > 2 units of blood transfusion ❑ Presence of other significant comorbidities | ❑ Bleeding stopped ❑ Patient is hemodynamically stable | |||||||||||||||||||||||||||||||||||
| Outpatient treatment | Admit to ICU | Admit to hospital ward | |||||||||||||||||||||||||||||||||||
Endoscopic management
| Assess the severity of bleeding | |||||||||||||||||||||||||||||||||||||||||||||||||||
| Intermittent scant bleeding | Massive bleeding | Moderate to severe bleeding | |||||||||||||||||||||||||||||||||||||||||||||||||
❑ Age ≥ 40 years ❑ Healthy stable patient ❑ Anorectal source of bleeding highly suspected | ❑ Age > 50 years ❑ Anemic patient | ||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Digital rectal examination ❑ Sigmoidoscopy | ❑Colonoscopy | ||||||||||||||||||||||||||||||||||||||||||||||||||
| ❑ Anorectal source of bleeding confirmed? | ❑ Anorectal source of bleeding not confirmed? | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Treat accordingly | Colonoscopy | ||||||||||||||||||||||||||||||||||||||||||||||||||