HOW I DO IT

Approach to lower gastrointestinal

bleeding
AUTHORSHIP

How I do it: Approach to lower gastrointestinal bleeding

Roque Senz MD
Eduardo Valdivieso MD, MSc
The Latin-American Advanced Gastrointestinal Endoscopy Training Center
Clnica Alemana, Universidad del Desarrollo
Santiago, Chile

Comment
David J. Bjorkman MD, MSPH
University of Utah School of Medicine
Salt Lake City,
Utah
USA

Summary
Tams Molnr MD, PhD
Tibor Wittmann MD, PhD
First Department of Medicine
University of Szeged
Szeged
Hungary

HOW I DO IT
Approach to lower gastrointestinal
bleeding
How I Do It
Roque Senz MD & Eduardo Valdivieso
Introduction
Lower gastrointestinal bleeding (LGIB) ranges from trivial to massive life-threatening blood loss
and is defined as bleeding that emanates from a source distal to the ligament of Treitz.
LGIB represents up to one third of the total cases of gastrointestinal bleeding. It is more
frequent in males and older patients. The mortality rate is about 3%6%, and the prognosis is
worse when LGIB occurs during hospitalization [1].
The bleeding is from the small bowel in about 9% of cases and the source remains
undiagnosed in 6% of patients with LGIB [2].
In practice, there are three common clinical scenarios related to LGIB: active bleeding, recent
bleeding, and chronic bleeding. International nomenclature defines acute LGIB as a bleeding of
less than 3 days duration associated with instability of vital signs, anemia, and/or need for
blood transfusion. Chronic LGIB is any passage of blood per rectum that results from
intermittent or slow loss of blood.
Although 80% of all LGIB stops spontaneously, and hemodynamic instability and the need for
transfusion are rare, the identification of the bleeding source often remains challenging and
rebleeding can occur in 25% of cases [3].
Clinical scenario
Clinically, the most common presentation of LGIB is hematochezia, rectorrhagia, but melena,
hemodynamic instability, anemia and abdominal pain can be seen.
Hematochezia is defined as gross blood seen either on toilet paper after defecation or mixed
with stool. Rectorrhagia means the expulsion of fresh red bright blood without stools, while
melena is defined as black stools resulting from the oxidation of hematin in the gut.
Hematochezia and rectorrhagia are frequent forms of LGIB, but melena could be present in the
setting of constipation.
Because of rapid transit time or massive bleeding, approximately 10% of cases of rectorrhagia,
are secondary to upper gastrointestinal bleeding (UGIB) [2].
Chronic bleeding can present as occult fecal blood, occasional episodes of melena, or even
small quantities of rectorrhagia.

OMED How I Do It
Approach to lower gastrointestinal bleeding

Unfortunately clinical signs are not reliable predictors of the source or severity of LGIB. As a
result, the approach to a case of LGIB depends mainly on the clinical setting, suggesting either
acute or chronic bleeding [4].
The hemodynamic stability of the patient and the rate of bleeding dictate the order in which
diagnostic and therapeutic procedures should be undertaken.
An initial hematocrit of less than 35%, abnormal vital signs 1 hour after medical management
and gross blood on initial rectal examination are all predictors of severe LGIB and adverse
outcome [5].
Attention should be paid to anal diseases, which are a common cause of rectal bleeding. A
history of anal pain, pruritus, and fresh red blood on the toilet paper is frequently the expression
of anal fissures or hemorrhoids.
Anal inspection, anoscopy and rectal examination are mandatory, because patients with clear
anal pathology will not require immediate colonoscopy or further investigations.
LGIB associated with an elevated blood urea nitrogen (BUN) or serum bilirubin denotes an
increased probability of UGIB. Nasogastric tube aspiration can help identify an upper
gastrontestinal bleeding source if it is positive, but a clear nasogastric tube aspirate does not
rule out an upper source. The presence of bile in the aspirate suggests that duodenal contents
have been sampled and further decreases the likelihood of an upper gastrointestinal source.
The presence of blood, clots or coffee ground material in the aspirate confirms UGIB and
upper gastrointestinal endoscopy should follow immediately.
After aspiration of the gastric contents, the nasogastric tube can also be utilized to start bowel
preparation with the instillation of 34 liters of polyethylene glycol (PEG) solution at a rate of
1 liter every 30 minutes. PEG, or phosphosoda (45 ml twice), is usually given orally. It usually
provides adequate colon cleansing within 34 hours. Intravenous prokinetics may be used in
order to avoid vomiting and to assure the purge progression.
The patients age affects the clinical approach to LGIB. In children and young patients, cow milk
allergy, polyps, Meckels diverticulum, inflammatory bowel diseases, and anal diseases should
be especially considered. Older patients are more likely to have diverticular disease,
angiodysplasia, ischemic diseases, colorectal cancer, inflammatory bowel diseases, polyps,
nonsteroidal anti-inflammatory drug (NSAID)-induced lesions, and lesions from prior
radiotherapy, and may also have anal diseases. Other vascular malformations are infrequent
but should occasionally be considered.
Young women could be affected by endometriosis, and when bleeding is episodic or chronic
colonoscopy would be better scheduled for menstruation days.
Specific indications and contraindications for diagnostic and therapeutic procedures
The diagnostic accuracy of colonoscopy ranges from 72% to 86% in the setting of LGIB. Cecal
OMED How I Do It
Approach to lower gastrointestinal bleeding

intubation is usually achieved in more than 95% of attempts. The yield from colonoscopy is
greater when done earlier in the hospital stay, and patients who undergo colonoscopy for LGIB
are reported to have a shorter length of stay compared with those who do not [6]. Colonoscopy
leads to the greatest number of specific diagnoses and directed therapy in acute LGIB. For the
vast majority of patients with LGIB, colonoscopy is the only intervention needed [7].
A negative technetium-labeled red blood cell nuclear scan rules out active bleeding. The test
can detect bleeding at the rate of 0.1 ml/min or greater. However, the results of scintigraphy can
be difficult to interpret, have poor accuracy in locating a bleeding site, and are poor predictors of
subsequent angiogram results. A limited colonic resection should not be based on only a
positive nuclear scan [8].
If the rate of ongoing arterial bleeding is at least 0.5 ml/min, angiography may show
extravasations of contrast into the lumen and identify a bleeding site. Angiography is an
invasive procedure, which can result in complications including contrast-induced renal failure,
arterial injury, and mesenteric ischemia. The accuracy of this procedure can be quite variable; it
detects only active bleeding and may miss lesions that bleed intermittently. Angiography can
identify neoplastic or vascular disorders and their locations, and can also reveal vascular
ectasias based upon the characteristic angiographic appearance. Angiographic therapy can be
provided, by means of intra-arterial vasopressin or terlipressin infusions. Intra-arterial
vasopressin infusion reduces the bleeding in 70%80% but the effect is not permanent.
Polyvinyl alcohol particles or microcoils, can be placed to occlude vessels; these have a more
persistent effect, but increase the risk of ischemia. Unfortunately, angiography is not readily
available in all settings, particularly at night or weekends. The use of systemic somatostatin or
octreotide infusion is controversial. These drugs reduce the splanchnic blood supply, permitting
the spontaneous cessation of bleeding or facilitating local endoscopic treatment.
Computed tomography (CT) angiography is a helpful new diagnostic tool that permits the
evaluation of the celiac axis as well as mesenteric arteries.
This technique may offer a very sensitive means to evaluate the source of acute LGIB, while
avoiding some of the morbidity and resource-intensiveness of contrast angiography, and may
provide unique morphologic information regarding the type of pathology. Investigation with the
more rapid and more widely available multidetector CT (MDCT), followed by either directed
therapeutic angiography or surgical management, may represent a reasonable algorithm for the
early evaluation and management of acute LGIB in which an active bleeding source is strongly
suspected [9].
Barium contrast studies have no role in the assessment of LGIB and should be avoided. These
procedures have low accuracy and can interfere with subsequent evaluation by colonoscopy or
angiography.
Occasionally, the LGIB source is in the small intestine. Push enteroscopy and capsule
endoscopy have been used for the assessment of obscure bleeding [10]. New double- and

OMED How I Do It
Approach to lower gastrointestinal bleeding

single-balloon technologies are employed in an improved method, which can be considered for
the assessment of acute LGIB; these single- or double-balloon enteroscopes have replaced the
push enteroscope where they are available. Enteroscopes have a therapeutic capability, for
instance for coagulation, polypectomy or mucosal resection, and for marking for subsequent
surgical treatment. Patients with a suspected bleeding area, defined by angiography,
scintigraphy or capsule, may be candidates for directed enteroscopic therapy; however, its utility
as a primary diagnostic/therapeutic procedure needs further evaluation.
Capsule endoscopy is easier to perform, does not require sedation, and is becoming
increasingly cheaper and more widely available. Capsule enteroscopy is considered the gold
standard for evaluating patients with obscure gastrointestinal bleeding, but its cost-effectiveness
is uncertain [11]. Capsule endoscopy identifies findings in 58% of patients compared with 28%
with other imaging procedures [12].
In our experience, video capsule endoscopy is best utilized after a negative colonoscopy, but
others recommend its earlier use as a first-step procedure for cases of midgut bleeding.
In exceptional conditions, an intraoperative endoscopy (possibly through an enterotomy) should
be performed, because of the persistence of bleeding with a probable small-bowel origin that
cannot be identified by other investigations.
Surgeons should be a part of the medical team from the very beginning, in case surgical
resection is required. Surgery is indicated when more than six units have been transfused, or
when hemodynamically significant persistent or recurrent bleeding occurs. Ideally surgery
should be directed at a specific bowel segment based upon prior evaluation. Empiric subtotal
colectomy should be reserved for life-threatening bleeding that cannot be located by vigorous
diagnostic efforts. The overall surgical mortality is about 5%10%.
Older patients or those with co-morbidities should be considered for earlier surgery, to avoid the
complications of multiple transfusion, prolonged hemodynamic instability, cardiovascular
impairment or coagulation disorders.
For all cases of confirmed or suspected LGIB, colonoscopy should be the diagnostic and
therapeutic procedure of choice. The use of other modalities in the setting of continuous,
clinically significant bleeding depends upon the availability of other diagnostic and therapeutic
methods (angiography, scintigraphy, etc).
Algorithm for management of LGIB
The very first steps must be to assure hemodynamic stability and to determine the need for
hospitalization in an intensive care unit. Volume resuscitation should begin at presentation and
continue through the diagnostic evaluation, as needed.
Adequate vascular access is essential. Coagulation tests, hemoglobin level, blood group
information, and blood to be used for labeled red cells scintigraphy can be obtained when an

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Approach to lower gastrointestinal bleeding

intravenous line is placed.

As a guide, we propose the algorithm for management of acute LGBI that is shown in Figure 1.
Figure 1. Management algorithm for lower gastrointestinal bleeding (LGIB).

Acute lower gastrointestinal bleeding

(LGIB)

Resuscitation and Evaluation

Physical examination/Orthostatics
Complete blood count (CBC)/Electrolytes/
Coagulation/Blood Type & Cross-match

Consider nasogastric tube

Negative aspirate
or
Aspirate not done

Oral purge
(Polyethylene
glycol [PEG]
lavage)

Negative
EGD

Colonoscopy

Massive bleeding

Positive aspirate
or
Risk factors for
upper
gastrointestinal
bleeding
(UGIB)

Surgical

Esophagogastroduodenoscopy
(EGD)

Positive EGD:
See UGIB
algorithm

consultation

Colonoscopy

Successful

Observation

Successful angiography
Embolization or
intra-arterial injection

Observation

Persistent
bleeding

Faster bleeding
(0.5 ml/min):
Angiography

Persistent
bleeding

Slower bleeding
(<0.5 ml/min):
Vasoconstrictor
drugs

Repeat
colonoscopy

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Surgery
Approach to lower gastrointestinal bleeding

We have also used another management algorithm for acute LGIB, which is based on
colonoscopic findings; this is shown in Figure 2.
Figure 2. Management algorithm for lower gastrointestinal bleeding (LGIB), based on
colonoscopy findings.

Colonoscopy

Source of bleeding
identified

Unable to visualize colon

endoscopically due to
severity of bleeding

Endoscopic
therapy
Faster bleeding
(>0.5 ml/min):
Angiography
Persistent
recurrent
bleeding
Bleeding
continues

Slower bleeding
(>0.5 ml/min):
Vasoconstrictor
drugs

Repeat colonoscopy

Angiography
Preoperative
location

Bleeding
stopped

Continued
bleeding
Consider
repeat
colonoscopy
Surgery

Surgery

Evaluation of small bowel

Esophagogastroduodeno-scopy
(EGD) if not done previously
Consider repeat colonoscopy

OMED How I Do It
Approach to lower gastrointestinal bleeding

Technique of colonoscopy in acute LGIB

Restoration of hemodynamic stability is the most important first step, but bowel cleansing can
begin as fluid resuscitation is being carried out. Ideally, colonoscopy should be performed as
early as possible, within the first 1224 hours of admission.
Careful examination, meticulously clearing retained blood and stool, is important. If angiography
or scintigraphy has been performed previously, special attention should be paid to areas
identified as suspicious by those studies. Care should be taken to avoid excessive air
insufflation during the procedure. Repeated aspiration of excess air can reduce the risk of
subsequent abdominal distension.
Every effort should be made to visualize the terminal ileum during the colonoscopy. If no blood
or clots are found in the small bowel the probable origin is restricted to the colon. A gentle and
meticulous withdrawal, searching for active bleeding sources or stigmata, similar to the upper
gastrointestinal process is required. Local rinsing in every segment is mandatory, to assure
ptimal visualization.
Patient preparation
The patient and relatives should be carefully informed about the clinical situation, the probable
outcomes, the diagnostic/treatment plan, the associated risks and their solutions. Informed
consent should be obtained for all necessary procedures with the patient having the opportunity
to have all questions answered.
Sedation
The specific approach to sedation for the procedure will depend upon the co-morbidities and
hemodynamic stability of the patient. It may be appropriate to have the services of an
anesthesiologist who can monitor and support the hemodynamic status of high-risk patients.
Equipment and accessories
Wide-channel colonoscopes should be available. An experienced endoscopy assistant should
be involved in the procedure. All the different devices that are potentially needed should be
available at the start of the procedure. This includes, but is not limited to, injection needles and
solutions, heater probes, electrocautery devices (including argon plasma coagulation, if
available), clips, loops and bands.
Several 100-ml syringes and fluid for vigorous colonic lavage should be available, to flush
through the biopsy channel, permitting a better view. Hydrogen peroxide solutions should be
avoided because these produce blood bubbles, impairing the view.

OMED How I Do It
Approach to lower gastrointestinal bleeding

Hemostatic procedures
Colonoscopic hemostasis techniques are based on the stigmata of hemorrhage that have been
identified in the upper gastrointestinal tract as predictors of upper gastrointestinal bleeding,
even though data are limited on the utility of endoscopic stigmata in predicting rebleeding in this
setting [13]. Local endoscopic therapy should be reserved for those with active or recurrent
bleeding.
In severe diverticulosis the location of the bleeding lesions may be indicated by the presence of
fresh blood or clots.
If active bleeding is detected, local epinephrine injection, 1/10 000 or 1/20 000 solution, should
be done into the area. In aged patients or patients with vascular impairment, epinephrine use is
restricted, or more dilute solutions could be used. Diverticula should be examined carefully, as
the bleeding vessel can sometimes be seen in the diverticular dome or on the lip of the
diverticulum. The bleeding vessel can be treated with a clip. If a bleeding diverticulum is
demonstrated but no vessel is visible, epinephrine injection should be done at the edge of the
diverticulum.
The combination of cautery and injection therapy may be useful for visible vessels, according to
uncontrolled studies. Clipping or banding could also be attempted according to the vessel
characteristics. If an adherent clot is found, it can be guillotined and the underlying lesion
treated more accurately. The area should be injected with dilute epinephrine prior to
manipulating the clot to decrease the risk of precipitating vigorous bleeding.
Thermal therapies, using a heater probe, electrocautery, or argon plasma coagulation have
similar efficacy. Bleeding lesions should be marked by a submucosal India ink tattoo, in order to
facilitate location of the lesion in subsequent endoscopic or surgical therapy. In the case of
angiodysplasia or angioma lesions, local epinephrine injection prior to thermal therapy is not
advisable, because the lesions disappear with the vasoconstriction preventing subsequent
therapy.
Submucosal saline injection can be used to produce a cushion that makes thermal treatment in
the cecum and right colon less dangerous. It is also advisable to aspirate the excess air to make
sure that the thickness of the bowel wall is maximized.
Some characteristics of LGIB

The most frequent causes of LGIB are diverticular disease and angiodysplasias [14].

60% of bleeding patients have diverticula but frequently these are not the source of
bleeding [15].

NSAIDs use increases the risk of LGIB from diverticula and NSAID-induced mucosal
erosions.

OMED How I Do It
Approach to lower gastrointestinal bleeding

It is unusual to find diverticulitis or local inflammation.

Diverticular bleeding usually presents with hematochezia, maroon material or bright red
blood. It is not a common cause of occult bleeding.

When bleeding stops spontaneously (as occurs in 75%80% of patients), 65%75% of

those patients do not rebleed.

Bleeding can occur from diverticula in the right colon.

Angiodysplasias are frequently seen in the cecum and ascending colon. If they are the
source of bleeding or if this is the only finding in a patient with recurrent LGIB, they should
be treated.

Angiodysplasia is present in 3%40% of patients with occult bleeding. Colonoscopy

detects 80%90% of the cases and it is potentially therapeutic.

Vascular ectasias and Dieulafoy lesions could be the cause of the local bleeding, and also
require local endoscopic treatment. Injection therapy plus coagulation or thermal treatment
or mechanical endoscopic procedures (clipping, and banding), could be useful.

Sometimes if the vessel is difficult to treat, radiological intervention (embolization) or

surgery is required.

Inflammatory bowel disease may be a cause of bleeding in 2%6% of LGIB cases. It is

more significant in Crohns colitis than in ulcerative colitis. Surgery is required in about
20%30% of these patients. Bleeding is usually diffuse but occasionally a vessel in an
ulcer could be clearly identified and locally treated.

Infectious colitis could be the cause of diffuse lesions that respond to specific treatment.

Ischemic colitis is another recognized cause of LGIB. It is more often diagnosed because
of diffuse vascular disease, aging of the population, cocaine consumption, vigorous athletic
activity, or cardiovascular surgery with hypotension and hormone therapies. It is more
frequent in the splenic flexure, descending colon and sigmoid colon because of the
characteristics of the blood supply.

Blue bubbles, ulcerated areas, and the presence of diffuse ectatic vessels and a relative
absence of bleeding at the time biopsies are taken may be clues pointing to ischemic
impairment. The findings may be asymmetric. A stenosis may be present if the ischemia is
chronic or recurrent.

Dark blue, black, or green coloring of the mucosa suggests severe ischemia that requires
urgent surgery in order to avoid perforation and peritonitis.

If a critical vascular stenosis is demonstrated, vascular surgery or radiological intervention

for angioplasty and stenting could be necessary.

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Approach to lower gastrointestinal bleeding

10

Polyps could be also a bleeding source, and can be treated with polypectomy.

Bleeding may also be seen at the site of a previous polypectomy or mucosal resection.
This can be avoided by careful attention at the time of the initial procedure. Large polyp
stalks can be pretreated with clipping or looping. Sometimes adrenaline injection of the
stalk produces vasoconstriction, permitting better coagulation or local inflammationof the
artery that permits hemostasis. Careful attention to the cautery and coagulation settings,
as well as to the snare technique can help reduce the risk of post-polypectomy bleeding.

Post-polypectomy bleeding that occurs immediately should be treated on the spot, by resnaring the stalk, adrenaline injection, electrocoagulation, looping or clipping.

Post-polypectomy bleeding can occur until the 17th day post procedure (mean 5th day).
About half of these require transfusions.

Aspirin, NSAIDs, antiplatelet drugs and anticoagulants can also increase the risk of postpolypectomy bleeding. The appropriate approach should be based upon the underlying
need for clot prevention in the individual patient. The risk of bleeding must be balanced
against potential thrombotic complications if the drug is stopped.

We have encountered (unpublished personal data) intestinal ischemia occurring after

prolonged colonoscopy for multiple difficult procedures, and resultant overdistension of the
bowel. Overinsufflation should be avoided, and excess air aspirated in these cases.

Colon cancer is also a cause of LGIB, and local treatment is indicated only for hemostasis,
very early cancers, or palliation. Definitive surgical treatment is indicated in most cases of
colon cancer.

Radiation colitis is also a common cause of LGIB. Prostate and gynecological cancers are
still indications for radiotherapy. Vascular spiders are the cause of such bleeding. Local
treatment could be achieved using argon plasma coagulation (APC) or multipolar
coagulation. The lower rectum can be treated using scope retroflexion.

Inflammatory bowel diseases (IBDs) are also a common cause of LGIB. Colonoscopy is
usually diagnostic. Ulcerative colitis is easily diagnosed due to its characteristic endoscopic
features of confluent inflammation starting in the rectum and extending proximally. Crohns
disease has a characteristic endoscopic appearance of segmentary inflammation and deep
ulcers.

Hemodynamically significant LGIBs due to IBD are uncommon and are usually treated
medically or surgically.

References
1

Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower
gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1997; 92: 419
424

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Approach to lower gastrointestinal bleeding

11

Peura DA, Lanza FL, Gostout CJ, Foutch PG. The American College of Gastroenterology
Bleeding Registry: preliminary findings. Am J Gastroenterol 1997; 92: 924928

Davila RE, Rajan E, Adler DG, et al. ASGE guideline: the role of endoscopy in the patient
with lower-GI bleeding. Gastrointest Endosc 2005; 62: 656660

Mant A, Bokey EL, Chapuis PH, et al. Rectal bleeding. Do other symptoms aid in
diagnosis? Dis Colon Rectum 1989; 32: 191196

Velayos FS, Williamson A, Sousa KH, et al. Early predictors of severe lower
gastrointestinal bleeding and adverse outcomes: a prospective study. Clin Gastroenterol
Hepatol 2004; 2: 485490

Bounds BC, Friedman LS. Lower gastrointestinal bleeding. Gastroenterol Clin N Am 2003;
32: 11071125

Green BT, Rockey DC, Portwood G, et al. Urgent colonoscopy for evaluation and
management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am
J Gastroenterol 2005; 100: 239523402

Levy R, Barto W, Gani J. Retrospective study of the utility of nuclear scintigraphic-labelled

red cell scanning for lower gastrointestinal bleeding. ANZ J Surg 2003; 73: 205209

Duchesne J, Jacome T, Serou M et al. CT-angiography for the detection of a lower

gastrointestinal bleeding source. Am Surg 2005; 71: 392397

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de Leusse A, Vahedi K, Edery J et al. Capsule endoscopy or push enteroscopy for first-line
exploration of obscure gastrointestinal bleeding? Gastroenterology 2007;132: 855862

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Mata A, Bordas JM, Feu F et al. Wireless capsule endoscopy in patients with obscure
gastrointestinal bleeding: a comparative study with push enteroscopy. Aliment Pharmacol
Ther 2004; 20: 189194

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Zuckerman GR, Prakash C, Askin MP, Lewis BS. AGA technical review on the evaluation
and management of occult and obscure gastrointestinal bleeding. Gastroenterology 2000;
118: 201221

13

Elta GH. Urgent colonoscopy for acute lower-GI bleeding. Gastrointest Endosc 2004; 59:
402408

14

Jensen DM. Management of patients with severe hematochezia with all current evidence
available. Am J Gastroenterol 2005; 100: 24032406

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Bloomfeld RS, Rockey DC, Shetzline MA. Endoscopic therapy of acute diverticular
hemorrhage. Am J Gastroenterol 2001;9 : 23672372

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HOW I DO IT
Approach to lower gastrointestinal
bleeding
Comment
David J. Bjorkman
While of great clinical significance, lower gastrointestinal bleeding (LGIB) is a less common
event than upper gastrointestinal bleeding. As a result, there are fewer prospective trials to
guide our diagnostic and therapeutic approach to this condition.
The review of the causes and clinical approach presented by Drs. Senz and Valdivieso is
excellent and comprehensive. I will not repeat the points they make, but will highlight areas
where our approaches may vary slightly, and emphasize points of great importance.
As mentioned by Drs Senz and Valdivieso, the clinical approach to the patient will be different,
depending upon whether the bleeding is acute, intermittent, or occult. I will focus on acute lower
gastrointestinal bleeding (ALGIB), as they have addressed the issues of occult and intermittent
bleeding which can be approached less urgently.
The causes of ALGIB vary with the patient population. Retrospective studies of the causes of
LGIB have given different information in different settings and varying patient demographics. It
is therefore difficult to generalize the frequency of specific causes of ALGIB to all patients.
Some common principles, however, appear to be universal. Elderly patients are more likely to
bleed from diverticula and vascular lesions than younger patients. Patients taking nonsteroidal
anti-inflammatory drugs (NSAIDs), antiplatelet drugs, or anticoagulants are more likely to have
ALGIB. The incidence of inflammatory bowel disease and colon cancer in the local population
will also affect the likelihood of these disorders causing the bleeding event.
Our approach to ALGIB is very similar to that described by Drs Senz and Valdivieso. The
primary initial goal is to assess the hemodynamic status of the patient, and provide appropriate
intravascular volume resuscitation. Tachycardia and orthostatic changes in blood pressure are
indications for rapid volume replacement. Initial volume replacement is done with an isotonic
solution (normal saline or lactated Ringers). The initial hematocrit or hemoglobin level may not
be an accurate assessment of the volume of bleeding until intravascular volume has been
replaced. Blood is transfused as indicated by the volume loss and underlying medical status of
the patient.
After initial hemodynamic stabilization the next step is to prepare the patient for colonoscopy as
soon as possible. Colonoscopy has been demonstrated to be the most accurate diagnostic test
for ALGIB and can be therapeutic in many situations [13]. Early colonoscopy also allows for
more rapid directed therapy and decreases the length of hospital stay [4].

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Approach to lower gastrointestinal bleeding

13

Preparation for colonoscopy should begin as soon as the patient is hemodynamically stable.
This can be done be giving a polyethylene glycol (PEG) solution either orally or through a
nasogastric tube. One liter of solution should be given every 3045 minutes until the intestinal
effluent becomes clear. We prefer this to sodium phosphate because of the ability to titrate the
amount of cleansing solution needed and because of the potential electrolytic effects of sodium
phosphate, particularly in elderly patients with impaired renal blood flow [5]. Prokinetic agents,
such as metaclopramide, may facilitate the administration of the PEG solution.
Vigorous bleeding from the upper gastrointestinal tract can also present as bright red blood,
accounting for 10%15% of cases of presumed ALGIB. If the patients history suggests a
possible upper gastrointestinal source of bleeding (NSAID use, history of peptic ulcers) an
upper gastrointestinal endoscopy should be performed prior to starting the colonoscopy
preparation. Prompt placement of a nasogastric tube allows for sampling of the gastric contents
for blood, clears the stomach for an upper endoscopy, if needed, and facilitates administration
of the PEG solution in preparation for colonoscopy.
The colonoscopy should be performed with anticipation of the need for additional flushing to
remove blood and retained clots, even after a vigorous purge. Careful evaluation of the entire
colonic surface is critical to identify possible bleeding sources. Stigmata of bleeding, similar to
those used for upper gastrointestinal bleeding (active bleeding, visible vessels), should be
treated at the time of colonoscopy. The method of treatment should be individualized according
to the type of lesion seen and the location in the colon. As the colon wall is thinner in the cecum
and right colon, I prefer to use dilute epinephrine injection followed by careful thermal therapy
after decompressing the colon to maximize wall thickness in the right colon. When argon
plasma coagulation (APC) is used the electrical current is transmitted to the colon wall via the
argon gas. This makes thermal therapy easier in some situations, but the depth of penetration
of the current and the tissue damage is difficult to control. For this reason I avoid using APC in
the right colon; I find it to be useful in treating larger areas of radiation damage in the rectum
because of the thicker rectal wall. Bleeding diverticula can be treated with thermal coagulation,
with or without epinephrine injection, if the vessel can be seen on the lip of the diverticulum. If
blood is coming from the opening without a visible vessel, or if the diverticulum is occluded by a
clot, the mouth of the opening can be injected with dilute epinephrine or saline to cause local
tamponade and promote clot formation. It can be helpful to tattoo the area of the bleeding lesion
for later location if bleeding persists or recurs. This can guide subsequent endoscopic or
surgical therapy.
In the event that a specific bleeding site cannot be identified and treated at the time of
colonoscopy, one can obtain information that may help to locate the general segment that is
bleeding by noting the location(s) of fresh blood. If blood is present in the descending colon but
not in the transverse or ascending colon, the bleeding site is probably distal to the splenic
flexure. It is particularly helpful to determine if blood is present in the terminal ileum, which
suggests a small-bowel source. This information may be very useful if bleeding persists and

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Approach to lower gastrointestinal bleeding

14

requires subsequent angiography or surgery.

When colonoscopy does not identify the site of bleeding, other diagnostic approaches should be
considered. There is no role for barium studies in the evaluation of ALGIB. They are unlikely to
identify a bleeding source and they interfere with more valuable studies, such as endoscopy,
angiography, and computed tomography (CT).
If bleeding has ceased and the patient is hemodynamically stable, a more deliberate approach
to diagnosis can be used, considering capsule endoscopy, enteroscopy, or CT, as outlined by
Drs Senz and Valdivieso for intermittent and occult bleeding.
If the active bleeding persists, the approach depends upon the volume of bleeding. Scintigraphy
using labeled red blood cells, can detect a slower bleeding rate (0.5 ml/min). Our experience
with scintigraphy has been disappointing. Often the bleeding slows to the point where it cannot
be detected, or the location of the bleeding site is poorly defined by the study. It may provide
information that guides subsequent angiographic diagnosis and therapy, allowing the radiologist
to more selectively evaluate the suspected bleeding vessel. For this reason radiologists may
request a bleeding scan before performing angiography.
Angiography allows both diagnosis and potential therapy when brisk bleeding persists. Local
infusion of vasopressin, or embolic therapy can slow, or stop bleeding, but also carry a
significant risk of causing local ischemia. Vasopressin also carries cardiac effects that may limit
its use.
CT angiography with high-speed, high-resolution scanners can identify both vascular
abnormalities that may be bleeding and soft tissue abnormalities that can be diagnostic. When
this technology is available it may obviate the need for angiography.
Surgical intervention should be a last resort for the treatment of continued vigorous ALGIB.
Every effort should be made to identify the bleeding segment of bowel prior to surgery, as
empiric hemicolectomy has a significant risk of missing the bleeding lesions. When colonoscopy
can define an area of bleeding, but cannot identify the specific lesion or provide treatment, the
information can be used to determine the section of bowel to be resected. A submucosal tattoo
left in the segment may guide subsequent urgent surgery and minimize the amount of bowel
that needs to be removed. Tattoos should be left at the site of endoscopic therapy to guide
subsequent surgery in case bleeding persists or recurs.
Finally, when a lower gastrointestinal source of bleeding cannot be found, the upper
gastrointestinal tract should be evaluated, as it accounts for 10%15% of ALGIB.
While the approach outlined here applies to most patients presenting with ALGIB, the individual
condition, situation and co-morbidities of the patient should ultimately guide the diagnosis and
treatment of a specific patient

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Approach to lower gastrointestinal bleeding

15

References
1

Elta GH. Urgent colonoscopy for acute lower-GI bleeding. Gastrointest Endosc 2004; 59:
402408

Jensen DM, Machicado GA. Diagnosis and treatment of sever hematochezia. The role of
urgent colonoscopy after purge. Gastroenterology 1988; 95: 15691574

Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonscopy for the diagnosis
and treatment of severe diverticular hemorrhage. N Engl J Med 2000; 342: 7882

Strate LL, Syngal S. Timing of colonoscopy: impact on length of hospital stay in patients
with acute lower gastrointestinal bleeding. Am J Gastroenterol 2003; 98: 317322

Beloosesky Y, Grinblat J, Weiss A, et al. Electrolyte disorders following oral sodium

phosphate administration for bowel cleansing in elderly patients. Arch Intern Med 2003;
163: 803808

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Approach to lower gastrointestinal bleeding

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HOW I DO IT
Approach to lower gastrointestinal
bleeding
Summary
Tams Molnr
Tibor Wittmann

Drs Senz, Valdivieso, and Bjorkmann have excellently summarized the causes, diagnostic
methods, and endoscopic therapies of lower gastrointestinal bleedings (LGIBs). We would like
to add some further practical notes based on our experience.
1

Endoscopic examination of the upper gastrointestinal tract is the first step in our practice in
the case of any manifestation of gastrointestinal bleeding; clear nasogastric tube aspirate is
not enough to exclude upper gastrointestinal bleeding (UGIB), especially in the case of
duodenal origin.

Examination of the ileum is very important during colonosopy indicated by gastrointestinal

bleeding, particularly if hemorrhage is also present in the cecum. However in such cases,
blood can flow back from the colon to the ileum through Bauhins valve.

The major diagnostic problem is caused by gastrointestinal bleedings originating in the

small bowel. Although capsule endoscopy can determine the source of bleeding, it is very
difficult to locate the exact segment and therapeutic intervention cannot be performed.
Therefore positive capsule endoscopy often results in surgery, during which intraoperative
endoscopy is essential.

The experience gained from the increasing number of single- and double-ballon
enteroscopic examinations allows a more frequent review of the whole length of the small
bowel and the use of therapeutic hemostasis, which could solve the problem of the
diagnosis and endoscopic therapy of acute small-bowel bleedings.

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Approach to lower gastrointestinal bleeding

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