Abdominal examination may reveal tenderness, distension, or a mass depending on the cause. If available, consider proctoscopy as well. The family history of colon cancer or inflammatory bowel disease (IBD) should also be noted.Ībdominal examination and digital rectal examination should be completed in all patients presenting with lower GI bleeds. Key details in the history should include whether the bleeding is recurrent or sporadic if there are associated symptoms and a detailed review of the patient's medications including, antiplatelets, anticoagulants, and NSAIDs. Patients can present with scant bleeding to massive hemorrhage. Therefore a thorough history is necessary. Patients presenting with lower GI bleeds can have varying symptoms and signs. Bleeding is usually self-limited but can be delayed up to one week after the procedure. Post-polypectomy bleeding is more common in patients older than 65 years with a polyp greater than 1 cm. Other disease processes practitioners should consider include vascular ectasias which are flat, red mucosal lesions in the cecum and ascending colon and represent 10% of lower GI bleeds. Inflammatory bowel disease (IBD) and NSAID use should also be evaluated in lower GI bleeds. The most common cause of lower GI bleeds in patients younger than 50 years is anorectal disorders, specifically, hemorrhoids. Patients with mesenteric ischemia require radiographic and/or surgical evaluation and intervention. Occlusive or thromboembolic events can affect much larger areas of the bowel and should be quickly evaluated with mesenteric angiography. These non-occlusive disease processes usually resolve with hydration and nonsurgical intervention. Non-thrombotic causes usually affect the watershed areas of the bowel, notably, the splenic flexure. It occurs in response to reduced mesenteric flow to the colon due to decreased cardiac output, vasospasm, or atherosclerotic disease. Ischemic colitis occurs in 20% of lower GI bleeds and is more prevalent in the elderly. The left colon is often more commonly affected as being the source of diverticular bleeds.Īpproximately, one-third of patients with presumed lower GI bleeds and heavy bleeding will have an upper GI bleed, particularly, if the patient presents with signs and symptoms of peptic ulcer disease or recent (non-steroidal anti-inflammatory) NSAID use. The prevalence of diverticular disease increases in elderly patients, particularly ages older than 80 years, patients with chronic constipation, and altered colonic motility. Therefore early identification and management are imperative. More than 80% of lower GI bleeds will stop spontaneously, and overall mortality has been noted to be 2% to 4%. The diverticular disease accounts for over 40% of lower GI bleeds and often presents as painless hematochezia. The patient typically appears well, hemodynamically stable. The differential diagnosis of these patients should include inflammatory, neoplastic and congenital. Lab work reveals patients with microcytic hypochromic anemia due to chronic blood loss. Many disease processes should be considered on the differential list including neoplastic disease, inflammatory, infectious, benign anorectal, and congenital.įinally, occult lower GI bleeds can present in patients at any age. The patient is usually hemodynamically stable. Moderate bleeding can occur at any age and presents as hematochezia or melena. The mortality rate may be as high as 21%. Massive lower GI bleeds are mostly due to diverticulosis and angiodysplasias. Lab work reveals a hemoglobin equal to or less than 6 g/dl. The patient is usually hemodynamically unstable with a systolic blood pressure (SBP) equal to or less than 90 mmHg, heart rate (HR) less than or equal 100/min, and low urine output. Massive bleeding usually occurs in patients older than 65 years with multiple medical problems, and this bleeding presents as hematochezia or bright red blood per rectum. Lower GI bleeds can be categorized further into three types: massive, moderate, and occult bleeding.
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