Etiology of lower gastrointestinal bleeding in adults
- Lisa Strate, MD, MPH
Lisa Strate, MD, MPH
- Associate Professor of Medicine
- University of Washington Medical School
Lower gastrointestinal bleeding (LGIB) refers to blood loss of recent onset originating from a site distal to the ligament of Treitz . It is usually suspected when patients complain of hematochezia (passage of maroon or bright red blood or blood clots per rectum). This is different from the clinical presentation of upper gastrointestinal (GI) bleeding, which includes hematemesis (vomiting of blood or coffee-ground-like material) and/or melena (black, tarry stools). Although helpful, the distinctions based upon stool color are not absolute since melena can be seen with GI bleeding from the right colon (or small intestine), and hematochezia can be seen with massive upper GI bleeding [2-4]. Therefore, it is imperative to exclude a massive upper GI bleed in hemodynamically unstable patients presenting with hematochezia . A nasogastric tube lavage that yields blood or coffee-ground-like material confirms the diagnosis of upper GI bleeding; however, lavage may not be positive if bleeding has ceased or arises beyond a closed pylorus. (See "Approach to acute upper gastrointestinal bleeding in adults".)
The epidemiology of GI bleeding appears to be changing. Studies indicate that the incidence of hospitalizations for LGIB is similar to that of upper GI bleeding, largely due to a decrease in upper GI events [6,7].
This topic review will focus on the major causes of LGIB originating from the colon and briefly summarize the management of some of these disorders. Although the definition of LGIB includes small bowel sources, the clinical presentation, management, and outcomes of small bowel bleeding are generally distinct from bleeding from colon sources . The diagnostic approach to patients with LGIB, suspected small bowel bleeding, and occult gastrointestinal bleeding are discussed separately. (See "Approach to acute lower gastrointestinal bleeding in adults" and "Evaluation of occult gastrointestinal bleeding" and "Evaluation of suspected small bowel bleeding (formerly obscure gastrointestinal bleeding)".)
The causes of lower gastrointestinal bleeding (LGIB) may be grouped into several categories (table 1):
●Anatomic (diverticulosis)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol 1998; 93:1202.
- Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988; 95:1569.
- Zuckerman GR, Trellis DR, Sherman TM, Clouse RE. An objective measure of stool color for differentiating upper from lower gastrointestinal bleeding. Dig Dis Sci 1995; 40:1614.
- Wilcox CM, Alexander LN, Cotsonis G. A prospective characterization of upper gastrointestinal hemorrhage presenting with hematochezia. Am J Gastroenterol 1997; 92:231.
- Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol 2010; 105:2636.
- Laine L, Yang H, Chang SC, Datto C. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. Am J Gastroenterol 2012; 107:1190.
- Lanas A, García-Rodríguez LA, Polo-Tomás M, et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol 2009; 104:1633.
- Prakash C, Zuckerman GR. Acute small bowel bleeding: a distinct entity with significantly different economic implications compared with GI bleeding from other locations. Gastrointest Endosc 2003; 58:330.
- Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc 1999; 49:228.
- Strate LL. Lower GI bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am 2005; 34:643.
- Boley SJ, Sammartano R, Adams A, et al. On the nature and etiology of vascular ectasias of the colon. Degenerative lesions of aging. Gastroenterology 1977; 72:650.
- Boley SJ, DiBiase A, Brandt LJ, Sammartano RJ. Lower intestinal bleeding in the elderly. Am J Surg 1979; 137:57.
- Korkis AM, McDougall CJ. Rectal bleeding in patients less than 50 years of age. Dig Dis Sci 1995; 40:1520.
- Strate LL, Orav EJ, Syngal S. Early predictors of severity in acute lower intestinal tract bleeding. Arch Intern Med 2003; 163:838.
- Peery AF, Barrett PR, Park D, et al. A high-fiber diet does not protect against asymptomatic diverticulosis. Gastroenterology 2012; 142:266.
- Meyers MA, Alonso DR, Gray GF, Baer JW. Pathogenesis of bleeding colonic diverticulosis. Gastroenterology 1976; 71:577.
- Ramanath HK, Hinshaw JR. Management and mismanagement of bleeding colonic diverticula. Arch Surg 1971; 103:311.
- Rege RV, Nahrwold DL. Diverticular disease. Curr Probl Surg 1989; 26:133.
- HORNER JL. Natural history of diverticulosis of the colon. Am J Dig Dis 1958; 3:343.
- Parks TG. Post-mortem studies on the colon with special reference to diverticular disease. Proc R Soc Med 1968; 61:932.
- Gostout CJ, Wang KK, Ahlquist DA, et al. Acute gastrointestinal bleeding. Experience of a specialized management team. J Clin Gastroenterol 1992; 14:260.
- Casarella WJ, Kanter IE, Seaman WB. Right-sided colonic diverticula as a cause of acute rectal hemorrhage. N Engl J Med 1972; 286:450.
- McGuire HH Jr. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg 1994; 220:653.
- Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1997; 92:419.
- Liebau H. [Blood pressure response to vasoactive substances and blood pressure regulatory mechanisms in pheochromocytoma]. Arch Klin Med 1968; 215:219.
- Nagata N, Niikura R, Aoki T, et al. Impact of discontinuing non-steroidal antiinflammatory drugs on long-term recurrence in colonic diverticular bleeding. World J Gastroenterol 2015; 21:1292.
- Aytac E, Stocchi L, Gorgun E, Ozuner G. Risk of recurrence and long-term outcomes after colonic diverticular bleeding. Int J Colorectal Dis 2014; 29:373.
- Bjarnason I, Macpherson AJ. Intestinal toxicity of non-steroidal anti-inflammatory drugs. Pharmacol Ther 1994; 62:145.
- Wilcox CM, Alexander LN, Cotsonis GA, Clark WS. Nonsteroidal antiinflammatory drugs are associated with both upper and lower gastrointestinal bleeding. Dig Dis Sci 1997; 42:990.
- Strate LL, Liu YL, Huang ES, et al. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology 2011; 140:1427.
- Chang CH, Lin JW, Chen HC, et al. Non-steroidal anti-inflammatory drugs and risk of lower gastrointestinal adverse events: a nationwide study in Taiwan. Gut 2011; 60:1372.
- Strate LL, Liu YL, Aldoori WH, Giovannucci EL. Physical activity decreases diverticular complications. Am J Gastroenterol 2009; 104:1221.
- Jansen A, Harenberg S, Grenda U, Elsing C. Risk factors for colonic diverticular bleeding: a Westernized community based hospital study. World J Gastroenterol 2009; 15:457.
- Tsuruoka N, Iwakiri R, Hara M, et al. NSAIDs are a significant risk factor for colonic diverticular hemorrhage in elder patients: evaluation by a case-control study. J Gastroenterol Hepatol 2011; 26:1047.
- Yamada A, Sugimoto T, Kondo S, et al. Assessment of the risk factors for colonic diverticular hemorrhage. Dis Colon Rectum 2008; 51:116.
- Suzuki K, Uchiyama S, Imajyo K, et al. Risk factors for colonic diverticular hemorrhage: Japanese multicenter study. Digestion 2012; 85:261.
- Okamoto T, Watabe H, Yamada A, et al. The association between arteriosclerosis related diseases and diverticular bleeding. Int J Colorectal Dis 2012; 27:1161.
- Nagata N, Niikura R, Aoki T, et al. Lower GI bleeding risk of nonsteroidal anti-inflammatory drugs and antiplatelet drug use alone and the effect of combined therapy. Gastrointest Endosc 2014; 80:1124.
- Foutch PG. Diverticular bleeding: are nonsteroidal anti-inflammatory drugs risk factors for hemorrhage and can colonoscopy predict outcome for patients? Am J Gastroenterol 1995; 90:1779.
- Foutch PG, Rex DK, Lieberman DA. Prevalence and natural history of colonic angiodysplasia among healthy asymptomatic people. Am J Gastroenterol 1995; 90:564.
- Foutch PG. Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993; 88:807.
- Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2014; 39:15.
- Diggs NG, Holub JL, Lieberman DA, et al. Factors that contribute to blood loss in patients with colonic angiodysplasia from a population-based study. Clin Gastroenterol Hepatol 2011; 9:415.
- Cappell MS, Gupta A. Changing epidemiology of gastrointestinal angiodysplasia with increasing recognition of clinically milder cases: angiodysplasia tend to produce mild chronic gastrointestinal bleeding in a study of 47 consecutive patients admitted from 1980-1989. Am J Gastroenterol 1992; 87:201.
- Gupta N, Longo WE, Vernava AM 3rd. Angiodysplasia of the lower gastrointestinal tract: an entity readily diagnosed by colonoscopy and primarily managed nonoperatively. Dis Colon Rectum 1995; 38:979.
- Theodoropoulou A, Sfiridaki A, Oustamanolakis P, et al. Genetic risk factors in young patients with ischemic colitis. Clin Gastroenterol Hepatol 2008; 6:907.
- Zuckerman GR, Prakash C, Merriman RB, et al. The colon single-stripe sign and its relationship to ischemic colitis. Am J Gastroenterol 2003; 98:2018.
- Chavalitdhamrong D, Jensen DM, Kovacs TO, et al. Ischemic colitis as a cause of severe hematochezia: risk factors and outcomes compared with other colon diagnoses. Gastrointest Endosc 2011; 74:852.
- Dignan CR, Greenson JK. Can ischemic colitis be differentiated from C difficile colitis in biopsy specimens? Am J Surg Pathol 1997; 21:706.
- Fernández E, Linares A, Alonso JL, et al. Colonoscopic findings in patients with lower gastrointestinal bleeding send to a hospital for their study. Value of clinical data in predicting normal or pathological findings. Rev Esp Enferm Dig 1996; 88:16.
- Macrae FA, St John DJ. Relationship between patterns of bleeding and Hemoccult sensitivity in patients with colorectal cancers or adenomas. Gastroenterology 1982; 82:891.
- Soulellis CA, Carpentier S, Chen YI, et al. Lower GI hemorrhage controlled with endoscopically applied TC-325 (with videos). Gastrointest Endosc 2013; 77:504.
- Ozdil B, Akkiz H, Sandikci M, et al. Massive lower gastrointestinal hemorrhage secondary to rectal hemorrhoids in elderly patients receiving anticoagulant therapy: case series. Dig Dis Sci 2010; 55:2693.
- Rogers BH. Endoscopic diagnosis and therapy of mucosal vascular abnormalities of the gastrointestinal tract occurring in elderly patients and associated with cardiac, vascular, and pulmonary disease. Gastrointest Endosc 1980; 26:134.