Lower gastrointestinal bleeding remains a difficult diagnostic and therapeutic problem. Most patients have lower gastrointestinal bleeding that stops spontaneously. These patients can be investigated by colonoscopy over the 24 to 48 h following a standard colonic preparation. For the 15% of patients whose bleeding continues, identification of the bleeding site is critical for subsequent management. […]

Overall, 25% of patients require a surgical procedure, usually for persistent hemorrhage resulting in hemodynamic instability. Provided that the site of bleeding has been accurately located by colonoscopy or angiogram, directed segmental resection results in low morbidity (0% to 13%) and is highly successful in stopping bleeding (85% to 99%). Every attempt, including intraoperative endoscopy, […]

In addition to its diagnostic capabilities, colonoscopy offers an opportunity for therapeutic intervention. Numerous reports of therapeutic techniques have been published. The largest series are summarized in Table 3. Up to 40% of colonoscopies for acute lower gastrointestinal bleeding have etiologies that are amenable to endoscopic therapeutic intervention. This includes such interventions as polypectomy, diverticular […]

The advent and expanded use of colonoscopy have dramatically changed the investigative pattern of lower gastrointestinal bleeding. Colonoscopy is clearly the diagnostic modality of choice in patients who have stopped bleeding and in those who can be prepared adequately. Usually, it can be done over the next 24 to 48 h, depending on the clinical […]

Vasopressin infusions of 0.2 U/min to 0.4 U/min stop bleeding in up to 80% of patients by inducing arteriolar vasoconstriction and bowel wall contraction. Vasopressin is generally continued for 12 to 48 h and then tapered off. Unfortunately, 50% of patients rebleed during the same hospitalization. The complications of vasopressin centre on its vasoconstrictive properties […]

Selective mesenteric angiography is a valuable tool to detect and potentially treat (via Pitressin infusion or embolization) sites that are bleeding at rates faster than 0.5 to 1 mL/min. Originally described in the 1960s, the technique is performed following placement of a trans-femoral arterial catheter. The superior mesenteric artery is usually injected first because bleeding […]

Although appealing in theory, the role of nuclear scintigraphy in the evaluation of lower gastrointestinal bleeding is unclear. Overlapping bowel and migration of Tc99m-labelled blood cells within the intestine (occasionally upstream) complicate interpretation and have led to false localization rates of up to 59%. Although some authors have reported a very high sensitivity of 73% […]

Radioisotope scanning can detect gastrointestinal bleeding rates as low as 0.1 mL/min. The general principle is to inject a radioactive substance that will extravasate into the bowel at the bleeding point, thereby localizing the site of bleeding. By viewing the initial site of extravasation, and allowing the contrast to accumulate and travel distally through peristalsis, […]

Other sources of gastrointestinal hemorrhage: The UGI tract should always be considered in patients presenting with bright red blood per rectum. Approximately 10% to 15% of cases of acute rectal bleeding have a UGI source. If an upper endoscopy and an evaluation of the colon are both negative, the small bowel should also be considered […]

Anorectal disease: Although hemorrhoids are the most common source of LGI bleeding, massive ongoing bleeding is distinctly unusual. Recurrent bleeding can occasionally lead to iron deficiency with subsequent microcytic anemia. Rarely, hemorrhoids may bleed profusely and require urgent surgical intervention. It is imperative to rule out perianal bleeding before pursuing other more complex and invasive […]