Aliment Pharmacol Ther 2005; 21: 1281–1298. doi: 10.1111/j.1365-2036.2005.02485.

x

Review article: the management of lower gastrointestinal bleeding
J. J. FARRELL* & L. S. FRIEDMAN  à§
*Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, CA;  Harvard Medical School, Boston, MA, USA;
Departments of Medicine, àNewton Wellesley Hospital, Boston, MA, USA, and §Massachusetts General Hospital, Boston,
MA, USA
Accepted for publication 30 January 2005

Approximately, 200 original and review articles were
SUMMARY
reviewed and graded. There is a paucity of high-quality
Several recent advances have been made in the evalu- evidence to guide the management of lower gastroin-
ation and management of acute lower gastrointestinal testinal bleeding, and current endoscopic, radiologic,
bleeding. This review focuses on the management of and surgical practices appear to reflect local expertise
lower gastrointestinal bleeding, especially acute severe and availability of services. Endoscopic literature sup-
bleeding. ports the role of urgent colonoscopy and therapy where
The aim of the study was to critically review the possible. Radiology literature supports the role of
published literature on important management issues in angiography, especially after a positive bleeding scan
lower gastrointestinal bleeding, including haemody- has been obtained. Limited surgical data support the
namic resuscitation, diagnostic evaluation, and endo- role of segmental resection in the management of
scopic, radiologic, and surgical therapy, and to develop persistent lower gastrointestinal bleeding after localiza-
an algorithm for the management of lower gastrointes- tion by either colonoscopy or angiography.
tinal bleeding, based on this literature review. There is limited high-quality research in the area of
Publications pertaining to lower gastrointestinal bleed- lower gastrointestinal bleeding. Recent advances have
ing were identified by searches of the MEDLINE database improved the endoscopic, radiologic and surgical man-
for the years 1966 to December 2004. Clinical trials and agement of this problem. However, treatment decisions
review articles were specifically identified, and their ref- are still often based on local expertise and preference.
erence citation lists were searched for additional publi- With increased access to urgent therapeutic endoscopy
cations not identified in the database searches. Clinical for the management of acute upper gastrointestinal
trials and current clinical recommendations were asses- bleeding, diagnostic and therapeutic colonoscopy can be
sed by using commonly applied criteria. Specific recom- expected to play an increasing role in the management
mendations are made based on the evidence reviewed. of acute lower gastrointestinal bleeding.

from 20.5 to 27 cases per 100 000 adult population at
INTRODUCTION
risk (0.03%). In contrast, the annual incidence rate for
Lower gastrointestinal bleeding is one-fifth to one-third upper gastrointestinal bleeding is reported to range from
as common as upper gastrointestinal bleeding and 100 to 200 cases per 100 000. As in upper gastroin-
generally has a less severe course. The annual incidence testinal bleeding, lower gastrointestinal bleeding stops
rate of lower gastrointestinal bleeding in the US ranges spontaneously in most cases (80–85%).1
The mean age of patients with lower gastrointestinal
Correspondence to: Dr J. J. Farrell, Division of Digestive Diseases, UCLA bleeding ranges from 63 to 77 years, with a reported
School of Medicine, UCLA Center for the Health Science, Los Angeles, CA
90095, USA. mortality rate of 2–4% (Table 1).2–7 The incidence
E-mail: jfarrell@mednet.ucla.edu rate of lower gastrointestinal bleeding increases with 

2005 Blackwell Publishing Ltd 1281

’ Clinical likely explained by the increasing prevalence of colonic trials and review articles were specifically identified.’ and ‘colonoscopy. and diverticulosis and colonic angiodysplasia with age. radiation colitis. * Includes inflammatory bowel disease. Specific This article focuses on the investigation and manage. The triage and evaluation of patients with lower gastrointestinal haemorrhage remains variable and METHODS largely institution-specific (Figure 1). digested blood per rectum.7–9. MEDLINE database for the years 1966 to December patients with lower gastrointestinal haemorrhage can  2005 Blackwell Publishing Ltd.6 41 3 9 16 5 14 Strate and Syngal (2003)69 66 3 30 3 6 21 14 28 NA. (1978)2 >65 2 40 11 14 12 NA NA Jensen and Machicado (1988)3 64. with a >200-fold increase from the age of 2004. especially severe bleeding. asia. and needs to be differentiated clinically from melaena.3. Publications pertaining to lower gastrointes. and finally to one or haematochezia. aortocolonic fistula. age. alternative therapies and then evidence from smaller mately 10–15% of patients presenting with acute severe or single RCTs or meta-analyses.8. Grade C evidence is gastrointestinal bleeding are diverticulosis. and causes of acute lower gastrointestinal bleeding Mean age Mortality Diverticulosis Angiodysplasia Cancer/ Colitis/ Anorectal  Otherà Study (years) (%) (%) (%) polyp (%) ulcer* (%) (%) (%) Boley et al. ‘all vs. mortality rates. well-designed randomized controlled trials (RCTs) defined as blood loss originating from a source distal with adequate statistical power to extremely positive to the ligament of Treitz and resulting in haemody. 9 This rise in incidence with age is most ‘gastrointestinal bleeding. their reference citation lists were searched for additional Haematochezia signifies bright red blood per rectum publications not identified in the database searches. Clinical trials and current clinical recommendations the passage of darkened. approxi. to sources account for 0. A practical reviewed. vasculitis and inflammation of unknown origin. haemorrhoids. Grade A evidence ranges from single or cumulatively Although severe lower gastrointestinal bleeding is large. angiodyspl. and anastomotic bleeding. § Study included only critically ill patients undergoing angiography. (1988)5§ 63 21 27 24 15 10 NA NA Richter et al. Age. anal fissure and idiopathic rectal ulcer. FRIEDMAN Table 1.0% of cases of severe high-quality case–control studies.   Includes haemorrhoids. The most common causes of lower more high-quality case series. is proposed. The dynamic This review aims to evaluate existing published data nature of severe bleeding leads to limitations with all regarding the management of lower gastrointestinal treatment strategies.’ 20–80 years. Aliment Pharmacol Ther 21. not available. S. it is bleeding. 1281–1298 . Finally. infectious colitis. recommendations are made based on the evidence ment of acute lower gastrointestinal bleeding. by using the terms ‘gastrointestinal haemorrhage. Grade B evidence haematochezia have an upper gastrointestinal source of ranges from high-quality studies of non-randomized bleeding identified on upper endoscopy. To best manage bleeding. 10–12 access to clinical studies of the higher grades. For the purposes of management. none’ outcomes among cohorts receiving namic instability or symptomatic anaemia. J. FARRELL & L. that of expert opinion based on first principles. Small bowel cohorts with and without the index treatment.1282 J. MANAGEMENT APPROACH TO PATIENTS WITH predictors of outcome in patients with lower gastrointes- ACUTE LOWER GASTROINTESTINAL BLEEDING tinal bleeding are discussed. useful to stratify patients based on the severity of tinal bleeding were identified by searches of the haemorrhage. (1995)7 70 2 48 12 11 6 3 6 Jensen and Machiado (1997)4 77 NA 23 40 15 12 5 4 Longstreath (1997)6 67 3. trauma from faecal impaction. and ischaemic colitis (see known physiology. were assessed by using commonly applied criteria. which suggests an upper gastrointestinal source. approach to the management of lower gastrointestinal bleeding. or bench research but without Table 1).5 NA 20 37 14 11 5 5 Leitman et al. à Includes postpolypectomy.

A digital rectal be broadly grouped into four overlapping categories. or malignant lesions. The examination.5] or thrombocytopenia (<50 000/ is especially limited in this group of patients because of lL) should prompt correction with transfusion of fresh the slow. For Angiography example. approximately 40% conservative therapy. Aliment Pharmacol Ther 21. Anticoagulant use does not preclude endoscopic haemodynamic stability in between episodes. oesophagogastroduodenoscopy). postural changes. a history of pelvic radiation therapy (for Video capsule prostatic or gynecologic malignancy) may point to Endoscopy radiation proctitis as a cause of rectal bleeding. examination is helpful in excluding anorectal pathology The first category includes 75–90% of patients and is as well as confirming the patient’s description of the characterized by minor bleeding that resolves with appearance of the stool. the patient’s age. – + Associated symptoms may provide clues to the source Colonoscopy EGD Treat of the bleeding. hospitalized for gastrointestinal bleeding. (with or without colonic purge) may play a diagnostic Blood transfusion requirement is determined by the and therapeutic role in this group. REVIEW: THE MANAGEMENT OF LOWER GI BLEEDING 1283 Acute severe hematochezia Clinical evaluation and resuscitation The patient who presents with acute lower gastrointes- History. or partial small Source identified. The third group frozen plasma or platelets respectively (grade C evi- has episodes of severe. fever. melaena. The second category is comprised of rectal carcinomas are palpable during a digital rectal of patients with chronic intermittent bleeding. Orthostatic hypotension. physical examination and resuscitation tinal haemorrhage may complain of passing bright red blood per rectum. vomiting. The fourth category patient’s age and the rate of bleeding and is also comprises patients with continual active bleeding. This may occur anywhere from 9 months to 4 years after Figure 1. sporadic nature of bleeding. identified. In addition. a history of abdominal pain.g. tachycardia. Similarly. pulmonary. or. life-threatening bleeding with dence). cirrhosis. 14 – Similarly. For most patients on warfarin who are the inconsistent nature of bleeding in this group.15–17 bleeding (EGD. 1281–1298 . Source not Source not weight loss. dark blood with clots. anticoagula- technetium (Tc)-99m red blood cell scans are useful tion should be reversed with fresh frozen plasma and prior to angiography. intestinal or colonic obstruction are important findings identified adequate exam inadequate exam in the differential diagnosis of inflammatory.  2005 Blackwell Publishing Ltd. urgent colonoscopy vitamin K. Treat Active bleeding? Yes medical history and medication history [e.2. diarrhoea. less Upper gastrointestinal source? commonly. colonic diverticula or angiodysplasia are more Treat + +/– treatment Enteroscopy likely to be a cause of lower gastrointestinal bleeding in +/– surgery a person over 70 years of age (grade B evidence). obstructive pulmonary disease. Algorithm for management of lower gastrointestinal radiation therapy. nonsteroi- dal anti-inflammatory drug (NSAID) use] may prove No critical in elucidating the cause of bleeding. dyspnoea. Alternatively. palpi- tations. Resuscitation should take place concur- rently with the initial evaluation of the patient. 13. Because of intervention. or chronic urgent angiography or even surgery. Assessment should include careful cardiac. Although lower gastrointestinal bleed- ing is usually painless. tachypnoea. fatigue. Pallor. infectious. These influenced by the presence of co-morbid conditions such patients may be hypotensive and are best served by as coronary artery disease. Angiography ized ratio (INR) >1. abdominal and rectal examinations. or syncope are suggestive of haemodynamic No Yes compromise.18 aetiology of bleeding in this group is often elusive and The presence of coagulopathy [international normal- probably best evaluated with colonoscopy. chest pain.

especially when In radiation proctitis. double-blind. Continuous electrocardiographic in which anti-inflammatories were compared with (ECG) monitoring is reasonable in high-risk patients. and oxygen saturation before. push enteroscopy and colonoscopy oscopy (see below). 42 recurrent haemorrhage. During a bleeding episode. obstruction. aspiration nal bleeding of obscure origin thought to be caused by pneumonia. Supplemental oxygen administration has been larized telangiectatic spots and ulcers.25.41 The principal complications hormonal therapy (oestrogen) to control gastrointesti. may lead to severe dures.6% formalin solution or 4% formalin solution patients with impaired pulmonary function or signifi- is used for irrigation. an extensive therapeutic endoscopic procedure is anti- ization and can stop bleeding by sealing the neovascu. observation. Empiric patients (0. The strongest evidence for the includes recording of the heart rate. sedation and monitoring during the endoscopy (grade C ride. blood pressure. FRIEDMAN a decrease in the haematocrit value of at least 6%. Upper endoscopy.30–38 suppression of the hypoxic ventilatory drive. 26 Formalin may sclerose and seal fragile Patients who may benefit from ECG monitoring include neovasculature in radiation-damaged tissues. Aliment Pharmacol Ther 21. have not been shown conclusively in controlled trials. Therapeutic procedures. The success of shown to reduce the magnitude of oxygen desaturation bleeding control is related to the accurate localization of during endoscopic procedures performed under sedation and application of formalin to all the bleeding sites. FARRELL & L.41. its postulated mechanisms of action evidence). In this setting. NSAIDs) and correction of coagulopathy.19–23 There is no than 50% of complications associated with endoscopy. perhaps caused by an higher rate of complications than do diagnostic proce- underlying obliterative arteritis. An alternative method is the direct cant pre-sedation oxygen desaturation and patients in application of gauze soaked in formalin (4% or 10%). hypoventilation. and should be considered mandatory. 44  2005 Blackwell Publishing Ltd. persistent haemodynamic instability despite aggressive resuscita- Endoscopy tion efforts warrants intervention.13%). controlled trial of 37 patients and after sedation. a gastrointestinal bleeding secondary to radiation procti- transfusion requirement of more than two units of tis. whom a prolonged or complex procedure is anticipated Three prospective case series (grade B evidence)27–29 (grade B evidence). overseda- systemically administered drugs in the management of tion.g.03–0.9%) than younger management of lower gastrointestinal bleeding. J. there are Elderly persons are at greater risk of complications of few specific medical therapies aimed directly at the gastrointestinal endoscopy (0. The risks of endoscopy performed in an emergency ment of bleeding secondary to radiation proctitis setting may be minimized through adequate resuscita- includes the use of sucralphate or formalin enemas. generally result in a nonhealing mucosal ulceration.39. Standard monitoring of sedated patients include stimulation of epithelial healing and formation undergoing gastrointestinal endoscopic procedures of a protective barrier.1284 J. 40 (e. S. myocardial infarction and bowel perfor- colonic angiodysplasia is controversial and may be ation. dence). evidence to support the initial use of octreotide or other the majority of complications are aspiration. or continuous active bleeding trolled studies of the use of formalin in the management merit admission to an intensive care unit for close of radiation proctitis. rectal sucralphate (grade A evidence)24 and a single although improved outcomes with such monitoring prospective study of rectal sucralphate (grade B evi. vasovagal episodes and airway lower gastrointestinal bleeding.43–45 Care must be taken to avoid and nine retrospective reports (grade B evidence). vascular telangiectasia and performed in an emergency setting.13. 1281–1298 . during randomized. There have been no prospective randomized-con- packed red blood cells. The nonendoscopic manage. cipated. Nonsurgical therapy may be performed during either angiography or colon. which can support the use of formalin in the management of lower lead to profound hypercapnoea. Cardiopulmonary events may account for more ineffective (grade A and B evidence). use of sucralphate enemas comes from a prospective respiratory rate. and those in whom directly to the mucosa produces local chemical cauter. are generally considered to be safe procedures. thereby those who have a history of a serious dysrhythmia or preventing further bleeding.24–4. especially in Either a 3. tion of the patient before the procedure and appropriate Sucralphate is a highly sulphated polyanionic dissacha. even in Other than the removal of possible aetiologic causes elderly patients with gastrointestinal bleeding. that occur in the elderly are haemorrhage. elderly persons. Application of formalin cardiac dysfunction.

throughout the small intestine. the scopy is warranted if there is medium to low suspicion of sensitivity of colonoscopy for detecting angiodysplasia an upper gastrointestinal source but may be misleading exceeds 80% (grade B evidence). it should be undertaken with the caveat that ted to enhance the appearance of angiodysplasia during the procedure should only be considered diagnostic if an colonoscopy in patients who have received meperidine actively bleeding lesion is visualized. 48–50 terminal ileum and proximal colon. as an upper source At colonoscopy. they may have a diameter factors for peptic ulcer.51–53 This inconsistency as seen in inflammatory bowel disease. the use of a narcotic Diagnostic colonoscopy. fern-like flat lesions evidence).59–63 in 11% of patients. non-acute and chronic inflammatory changes likely to be from the right colon. For example. >75% of diverticula shed areas: splenic flexure. When the colon is examined completely. the endoscopists prefer to perform a total colonoscopy as the use of naloxone may result in discomfort for the patient. However. upper gastrointestinal lesions were diagnosed strictures is pathognomonic of NSAID injury. portal hypertension. of the bowel. or rectosigmoid are found in the left colon. with and no lesions to account for bleeding in only 6% (grade B normal intervening mucosa. REVIEW: THE MANAGEMENT OF LOWER GI BLEEDING 1285 Upper endoscopy.6 When exception of the rectum in most cases. or angi.57 Although angiodysplasia can be found gastrointestinal source as the cause of haematochezia. with the to be from the left colon in 60% of cases. Although the historical view has been particularly when the procedure is prolonged by a that colonoscopy in patients with severe haematochezia therapeutic intervention. Aliment Pharmacol Ther 21. clots. the bleeding is observed copy reveals ulceration of the colonic mucosa. in fact. ischaemic colitis and cleansing (grade B evidence). the source is more necrosis. bleeding from angi- In the presence of large-volume upper gastrointestinal odysplasia in the small bowel usually presents as iron- bleeding. angiodysplasia are recognized by their will be found in 10–15% of such patients (grade B characteristic appearance as red.103 testinal source should be considered. For patients with severe colonoscopy for the diagnosis of less-severe diverticular haematochezia and hypovolaemia. 1281–1298 . it is prudent to provide airway protection by deficiency anaemia with faecal occult blood and rarely intubating the patient prior to upper endoscopy (grade C as severe haematochezia. bleeding. Nasogastric (NG) lavage before upper endo. where pills may In one study in which upper endoscopy was performed reside for a longer period of time than in other segments before colonoscopy in 80 patients with ongoing haemato. Non-occlusive colonic evidence). is impractical because of inadequate visualization. or coffee grounds-appear. These strictures are typically multiple in number. followed by the ing material is present in the NG aspirate. A pale mucosal halo may be seen around odysplasia.3 Endoscopy or push enteroscopy ought to be consisting of ectatic blood vessels that appear to radiate considered early in patients with a history of or risk from a central feeding vessel. with a predilection for the lower gastrointestinal bleeding (grade B evidence). presumed small-bowel lesions in 9%.54–57 Colonic angi- if only clear fluid without bile (or blood) returns (grade odysplasia are most common in the caecum and C evidence). Additionally. Other specific diagnostic features at colonoscopy colonoscopy is. However. If by transiently decreasing mucosal blood flow. right colon. When colonoscopy is used junction. A lower endoscopic study is well medication for sedation and analgesia may decrease the established as the diagnostic procedure of choice in the sensitivity of colonoscopy for detecting angiodysplasia setting of acute lower gastrointestinal haemorrhage. the two tests.3. sigmoidos- to diagnose diverticular bleeding.47 The diagnostic accuracy radiation colitis. Histology reveals angiography is used for diagnosis. upper sigmoid colon (18%) and rectum (14%) (grade B endoscopy must be performed to exclude an upper evidence). an upper gastroin. proximal ascending colon (54%). Radiation  2005 Blackwell Publishing Ltd. In patients with ischaemic colitis. Diagnostic endoscopic studies should may reflect differences in diagnostic sensitivity between be undertaken only after the patient has been haemo.58 Unfortunately. Colonic ulcers caused by NSAIDs are of colonoscopy ranges from 72 to 86% in patients with often sharply demarcated. a poor bowel evidence).3 These results are superior to those achieved ischaemia most commonly involves the so-called water- with arteriography. preparation may lead to incomplete evaluation of the colonic mucosa. of 2–10 mm. many for sedation (grade B evidence). the lesion.46 If blood. The development of diaphragm-like chezia. feasible and useful after rapid include NSAID-related disease. initial evaluation. with angiography being less sensitive than dynamically resuscitated. Admin- sigmoidoscopy is selected as the initial endoscopic istration of intravenous naloxone has been demonstra- approach.

such scopes and endoscopic accessories are necessary for as ethanolamine. FRIEDMAN proctitis typically demonstrates characteristic telangiec. time to colonoscopy has evidence).73 Use of either small or to improved diagnostic yield rather than therapeutic large probes. for which large probes. even with the use of energy and with lower gastrointestinal bleeding.] Approximately 30 min before the purge bipolar coagulation. Injection therapy with sclerosing agents. Suitable large-channel endo. adrenaline injection and thermal coagulation (with a ization and lower overall costs per patient (grade B bipolar or heater probe) is recommended (grade C evidence). However. and C evidence). coagulation) is lower gastrointestinal bleeding (grade B and C evi. low-power settings (10–15 W). administration via an NG tube is went endoscopic therapy with adrenaline injection. Insufficient performed in an emergency (within 12 h of admission) numbers of patients with these stigmata in the setting is safe and effective (grade B evidence). evidence). formed. For morrhage. employed. and those with severe congestive band ligation and placement of haemoclips (grade B heart failure may require diuresis. 75–79 One study reported that patients solution every 30–45 min until the effluent clears with demonstrable diverticular bleeding who under- (usually 5–8 L total). Braintree Laborator. a combination of scopic evaluation may reduce the duration of hospital.g.86–88 To prevent brisk bleeding from because the risk of colonic perforation may be increased angiodysplasia when contact electrocautery is per- in this setting (grade C evidence). FARRELL & L. compared with a 53% rebleeding rate in patients who ties. moderate There is no consensus regarding the need for a colonic tamponade pressure. In a widespread spectrum of patients experimental animals. 65. complica. A sulphate or polyethylene glycol long coagulation pulses are recommended (Table 2). Occasionally. Colonic diverticular bleeding is amenable to haemos- ies. 1281–1298 . MA. 66 In addition. except in association with haeman- (grade B evidence). The dose can be repeated every 4–6 h if nausea received conservative medical therapy alone (grade A results or if further purge is necessary.74 These dence). (PEG)-based purge (e.3. placement intervention. 65.90–92  2005 Blackwell Publishing Ltd. vessels. This recommendation is supported in part by been shown to be an independent predictor of the length demonstration of the safety of colonic endotherapy in of hospital stay. and successful purge. bipolar coagu- patients who are not able to drink a litre of purge lation. large angiodysplasia should be cauterized from the outer margin towards the centre to obliterate feeder Therapeutic colonoscopy. 64. extra effort of the guidelines are in contrast to those for gastroduodenal nursing staff and patient is required to ensure a ulcers. Aliment Pharmacol Ther 21. particularly for massive diverticular hae. or both.4. may improve the diagnostic and therapeutic most actively bleeding lesions or those with adherent outcome and prevent the need for surgical intervention clots in the colon. a noncontact Applications of colonoscopic haemostasis techniques method. Braintree. S. [For tasis with adrenaline injection therapy. and application of the probe until purge prior to colonoscopy in a patient with active adequate whitening of the site (i. (grade C evidence).65. early colono. observed are recommended (grade C evidence). has also been described for control of effective diagnostic and therapeutic colonoscopy in the bleeding from colonic angiodysplasia but is not widely management of acute lower gastrointestinal bleeding.69 of the probe directly on the bleeding point. 64–67 Early of lower gastrointestinal bleeding have been reported to intervention.89 Argon plasma coagulation. J. 67–70 In fact. 48. recommended.80–85 tion rates are low with PEG-based purges. has been used increasingly for the treatment of is based on identification of the same stigmata of bleeding colonic angiodysplasia (grade B evidence). gastrointestinal tract as predictors of recurrent upper Several recent studies have shown that colonoscopy gastrointestinal haemorrhage from ulcers. 71. had no recurrence of is started.65 Less frequently employed methods for patients with chronic kidney disease may require controlling diverticular bleeding include endoscopic dialysis after purging. or both.e. determine their usefulness in predicting outcome. Only an Conventional endoscopic treatment of colonic angi- experienced endoscopist should perform colonoscopy in odysplasia is performed with contact thermal probes an actively bleeding patient with an unprepared colon.4. 10 mg metoclopramide can be administered bleeding during the 30-month follow-up period. when intravenously for its prokinetic and antiemetic proper. USA) is administered orally.4.1286 J. the reduction in pressure parameters far higher than those used in a the length of hospital stay was shown to relate primarily clinical setting (grade C evidence). firm tamponade. giomas and internal haemorrhoids. haemorrhage that have been identified in the upper tasias at colonoscopy. GoLytely. 72 If it is prescribed.

therapy. devices (grade B and C evidence).93. bipolar electrocautery in postpolypectomy bleeding. 102–113 Endo- Massive bleeding that occurs at the time of polypectomy scopic coagulation with a variety of devices has been (early postpolypectomy bleeding) is typically arterial in reported to be effective for the control of radiation- nature and results from inadequate haemostasis of the induced bleeding. In the event of early postpolypectomy bleeding.90 No comparative pros. These include loop pective studies have compared contact and noncontact ligation of the remaining polyp stalk. different types of coagulation probes is usually self-limited and resolves with supportive care or lasers have been used: neodynium-YAG laser in in more than 70% of cases. 94 Delayed bleeding radiation proctitis. Sixteen relevant studies have looked at the role of local mostasis can generally be controlled by resnaring the endoscopic control of bleeding from radiation proctitis. 35. endoscopic band endoscopic treatment of bleeding colonic angiodys. Extra care must be taken when treating lesions in the polypectomy site. therapy in the treatment of chronic rectal bleeding from lation) current in the polypectomy snare (grade C rectal telangiectasia (grade A evidence). have proven safe and effective. rather than pure cutting electrocautery often required.114 Twenty-one evidence). 7. delayed polypectomy bleeding.24. Although these case polypectomy. 95–101 cation of colonoscopy performed for polypectomy and The endoscopic management of lower gastrointestinal accounts for approximately 2–8% of cases of acute lower bleeding from radiation proctitis represents a specific gastrointestinal bleeding (grade B evidence). For persistent or severe bleeding at a patients were randomized to treatment with either a  2005 Blackwell Publishing Ltd. Aliment Pharmacol Ther 21. Several treatment sessions are use of blended. REVIEW: THE MANAGEMENT OF LOWER GI BLEEDING 1287 Table 2. injection of adrenaline followed by thermal plasia. 34. likely as a result of the sloughing of the series all refer to the use of ablative therapy in late- eschar at the polypectomy site. 25.80. Scarring and re-epithelization with more currents in the polypectomy snare (grade C evidence). the frequency of delayed three and heater probes in two reports. 48 management problem. 1281–1298 . argon lasers in four. The technique is generally used to blood vessel in the polyp stalk.93. Reduction in the risk of coagulate focal bleeding telangiectasias rather than the early postpolypectomy bleeding can be achieved by the entire friable mucosa. The only postpolypectomy bleeding as a cause of acute severe randomized prospective study in this area compared haematochezia is increasing. and application of endovascular clipping Postpolypectomy bleeding is the most frequent compli. Polyp stalk radiation colitis bleeding Diverticulosis. the remaining 14 have been retro- Delayed bleeding may occur up to 15 days after spective series or case reports. ligation. stalk of the polyp and applying pressure (grade B and C Apart from one randomized controlled trial and one evidence). a variety of endoscopic techniques caecum to avoid perforation. In contrast to early eight. 94 prospective series.3. UCLA Center for Ulcer Research and Education (CURE) Hemostasis Research Group colonoscopic technical parameters for heater probe and bipolar electrocoagulation of bleeding colonic lesions4 Angiodysplasia. hae. normal tissue tend to occur over time. stops coagulum stops stops vessel and coagulum underlyingstigma treated * Consider injection with 1 : 10000 adrenaline prior to endoscopic coagulation with bipolar or heater probe. possibly because of the endoscopic bipolar electrocoagulation and heater probe increasing use of a blended (rather than pure coagu. 32. or ulcer bleed Active Nonbleeding Active Active Nonbleeding Cause bleeding visible vessel bleeding* bleeding* visible vessel Adherent clot* Bipolar coagulation Large Large or Large Large or Large or small Large or small probe size small small Power setting (W) 10–16 10–16 16–20 12–16 12–16 12–16 Pulse duration (s) 1 1 1–2 1–2 1–2 1–2 Heater probe size Large Large or small Large Large Large Large Power setting (J) 10–15 10–15 15–20 10–15 10–15 10–15 Pressure Light Light Moderate Moderate Moderate Moderate Endpoint Bleeding White Bleeding Bleeding Flatten visible Clot eliminated.

and randomized trials that compare surgical and endoscopic treatment sessions were repeated with the same probe management of rectal bleeding from haemorrhoids.133.17. red blood cells is the persistence of background activity bleeding rectal Dieulafoy’s lesion). scarring. Several small retrospective reports have reported an ulation in which electrosurgical current is delivered to accuracy rate of 54–79% for localizing large bowel the tissue through argon gas. the short  2005 Blackwell Publishing Ltd.130 Yet. plain after treatment revealed that rectal bleeding. S. pain.132 coagulation is a noncontact technique of electrocoag.g.1 mL/min. there have been no formal prospective detect a bleeding rate as low as 0. FARRELL & L. and are typically in blood vessels and the blood pool throughout the reported as single cases without any formal prospect. 134 limited (2–3 mm). and on an out-patient basis. In both groups.1–0. tenesmus and abdominal distention. Aliment Pharmacol Ther 21. the depth of coagulation is bleeding (grade B evidence). The role of double-contrast barium enema (DCBE) in the During follow-up endoscopy.105–107. colonoscopy if bowel perforation or obstruction is ized studies that reported success with either heater suspected. 112. is treatment for persistent or recurrent haemorrhoidal easier to detect because background activity is absent. FRIEDMAN heater probe or a bipolar electrocoagulation probe. which completely has gained popularity as an alternative to surgical clears the blood pool by 10–15 min after injection. study. there was a statistically significant decrease in severe bleeding. provided that peak aortic enhancement bleeding related to radiation proctitis. Evaluation with either radionuclide imaging or angiog- several treatment sessions usually are required to raphy (see later) may be appropriate in patients with achieve control of bleeding (grade B evidence). but Radiography a reduction in the number of units of blood transfused per cases was only seen in the heater-probe group. study (grade B evidence). until the bleeding resolved.g.5 mL/min and is more sensitive than ulcer and rectal stricture. Argon plasma reaches 100 Hounsfield units (Grade C Evidence). there was resolution of evaluation of lower gastrointestinal bleeding is decreas- the telangiectasias. long-term Radionuclide imaging detects active bleeding at complications include anorectal pain. Radiographic evidence of thumbprinting is probe or bipolar electrocautery used either higher or indicative of transmural injury to the colon as a result of lower power settings than those used in the randomized ischaemic or infectious colitis. The relative applied to the management of other sources of lower disadvantage of using [99Tcm] pertechnetate-labelled gastrointestinal bleeding (e. bleeding despite conservative therapy (grade B evi. 1281–1298 . endoscopic band ligation. as in radiation-induced proctitis. However.1288 J. the amount of bleeding needed for detection.131 Bleeding rates <0. bleeding colonic varices. in all cases in both groups. For large bleeding surfaces. 116 The benefit of YAG There may be an evolving role for multidetector laser in the management of bleeding related to computed tomography (MDCT) for localizing acute radiation proctitis has also been reported in several lower gastrointestinal bleeding as well as predicting retrospective series (grade B evidence).127–129 For example. massive haemorrhage that precludes colonoscopy or in 113. abdominal radiography should be performed prior to and general health had improved. endoscopic netium sulphur colloid or [99Tcm] pertechnetate- clipping and argon plasma coagulation) have been labeled red blood cells can be used. or epithelial replacement ing. 27. angiography but less specific than endoscopic or Some of the more recent developments in endoscopic angiographic study (grade B evidence).4 mL/min are detectable popularity for the management of lower gastrointestinal in swine. argon plasma coagulation has gained dence).135 Either tech- haemostasis (e. The technique can be used to treat large surface areas of mucosa to achieve haemostasis Radionuclide imaging easily. In addition to the suboptimal quality of DCBE. Other nonrandom. Patient interviews 6 months patients often prefer colonoscopy. safely. MDCT is highly sensitive and specific for the reported. chronic rectal rates of 0. 117–120 the treatment potential of arteriography and emboliza- Typically a power setting of 20–90 W has been tion. thereby theoretically increasing the threshold for ive or randomized evaluation (grade B and C evi. Although imaging with technetium sulphur colloid can dence).115. 121–126 Short-term complications include anorectal whom a bleeding source is not identified on colonoscopy. endoscopic band ligation contrast. In dence). J. technetium sulphur colloid. diagnosis of colonic angiodysplasia (grade A evi- More recently. tenesmus.

the intensive care unit for most patients. ongoing haematochezia.e. It also causes which should be performed within 1 h of positive important side-effects including abdominal pain and is scintigraphy. Indirect evidence of evidence). at supplied by the superior mesenteric artery (grade B baseline and up to 1–4 h later.145 Vasopres- red blood cell scanning.138. but does not confirm.50. 136–139 a bleeding lesion (such as an early-filling vein of A bleeding scan study may be done while the patient angiodysplasia or neovascularity of a neoplasm) sug- has ongoing haematochezia. if tinal bleeding rate of at least 1 mL/min for accurate necessary. or small veins that scan is positive. present in the intravascular space. angiography. 1281–1298 . ability to localize the bleeding source bleeding sufficiently to warrant an angiographic study. 150 Haemodynamically stable patients with severe but Unfortunately.137 Therefore. Aliment Pharmacol Ther 21. for evaluation of lower gastrointestinal bleeding. day or night (grade C evidence). before or after the evidence). the patient must have active bleeding when of angiography for the detection of a gastrointestinal the image is taken in order to demonstrate extravasa. delayed scans are asia are the most common findings when angiography less efficient in localizing the bleeding site (grade B is positive and account for 50–80% of sources in bowel evidence).145. (when one is identified). bleeding source ranges from 40 to 78% (grade B tion.5.143 Unfortunately.142 contraindicated in patients with clinically significant Patients who are haemodynamically unstable with coronary artery disease. imaging following injection of [99Tcm] pertechnetate-labelled red blood cells is preferred and Angiography is performed only if there is a gastrointes- can be performed at 30-min intervals for up to 24 h. thereby decreasing the contrast dye load. bleeding recurs in up to 50% of patients intermittent bleeding should be evaluated with [99Tcm] after cessation of the vasopressin infusion. which Angiography may be episodic. and imaging can be gests. Whereas early scans (<4 h after baseline) may be evidence). or push enteroscopy is recommended Angiography has a specificity of 100% but a sensitivity before emergency surgery is considered. administered. of contrast into the lumen is observed. requiring admission to diagnosis should necessitate an urgent angiography. because the labelled red The examination is not definitive unless extravasation blood cells stay in the vascular space for at least 24 h. thereby allowing detection of intermittent detection of extravasation of contrast into the bowel bleeding. thus sparing them the risks nal haemorrhage in up to 91% of patients with lower and costs of a nondiagnostic arteriographic study (grade gastrointestinal bleeding caused by either diverticular B evidence). A positive red blood cell sin infusion is labour-intensive.148 Angiography remains the gold standard patient starts the oral purge prior to colonoscopy) are for the diagnosis of angiodysplasia. The overall yield However. early-bleeding scans (i. REVIEW: THE MANAGEMENT OF LOWER GI BLEEDING 1289 half-life of the colloid within the vascular system scintigraphy and instead undergo resuscitation and requires active bleeding at the time the radionuclide is angiography as soon as possible (grade C evidence). In angiography include the lack of requirement for bowel addition to its role in determining which patients are preparation. vascular tufts. Following injection recommended in patients who are hospitalized for of contrast. Haemostasis can be achieved by intra- 140 Radionuclide screening appears to increase the arterial infusion of vasopressin or arterial embolization diagnostic yield of arteriography by a factor of 2.149 Advantages of imaging is generally performed before angiography. The study can be performed imaging may allow a more selective angiographic without a colonic purge or while a purge is being study. fill early.147 Intra-arterial infusion screening out-patients who are not actively bleeding at of vasopressin is successful in controlling gastrointesti- the time of the examination. and possibility of therapeutic localization of the bleeding source by radionuclide intervention in some cases. a confirmatory test such as colonoscopy. Radionuclide imaging is well tolerated by lumen. angiodysplasia are recognized by ectatic severe. thereby limiting for localizing bleeding. Even if the bleeding slow-emptying veins.151 A longer acting synthetic severe unremitting bleeding should forego nuclear vasopressin analogue (terlipressin) has been used  2005 Blackwell Publishing Ltd. a potential bleeding site.141 disease or angiodysplasia (grade B evidence).4 by via the angiographic catheter. Radionuclide of only 30–47% (grade B evidence). ranging from 24 to 91% (grade B the detection of the causative lesion. 144–147 Diverticular disease and angiodyspl- helpful in localizing the bleeding site. repeated over the next 24 h. Therefore. bleeding is frequently inter- patients but is limited by highly variable accuracy rates mittent and may occur at a lower rate.

176 a greater propensity for rebleeding (grade C evi. and there is a need for urgent apy required emergency surgery for either failure to surgery because of an otherwise high mortality rate. require surgery. Transcatheter embolization is a more definitive means of controlling haemorrhage than is intra-arterial infu- Small bowel evaluation sion of vasopressin. Small bowel evaluation in patients who are and embolotherapy was eventually eschewed in favour haemodynamically stable may be performed with push of local vasoconstrictive therapy (i. with the patients with angiodysplasia treated by embolother. will not systemic side-effects of vasopressin are also avoided. Aliment Pharmacol Ther 21. bleeding from the right colon and caecum may recurs (Table 3) (grade B and C evidence)12. colonic infarction. 157 probably because of the predilection of particularly in patients with renal failure or severe angiodysplasia for the right colon. lower gastrointestinal bleeding. gelfoam. the disadvantages of vasopressin coupled endoscopy provides imaging of the entire small bowel with the availability of microcatheters led to the and is well tolerated by patients. The endoscopic and angiographic examinations be candidates for non-operative therapy have a sub- are complementary. be controlled with nonsurgical therapies. there have been over 150 reported cases of bleeding (grade B evidence). the blood transfusion therapeutic implications for angiotherapy. J. S. and polyvinyl alcohol particles.142. embolization proximal to the mesenteric border of the colon via larger An evaluation of the small bowel is indicated in those catheters led to a rate of bowel infarction that ranged patients with gastrointestinal bleeding in whom upper from 13 to 33% (grade B evidence). or has undergone a the absence of colonic infarction does not ensure a colonoscopy that has failed to identify the bleeding favourable outcome.36 control bleeding or rebleeding (grade B evidence). However. When first introduced. including immediate cessation of bleeding without the need for prolonged infusions or Most patients with severe lower gastrointestinal bleed- management of an indwelling arterial catheter. which has remained the procedure of choice until proximal 60 cm of the jejunum.142. In some cases of non-occlusive colonic ischaemia. Video capsule endo- development of microcatheter embolization using scopy is reported to identify the bleeding source in microcoils. In terms of requirement is greater than 6 U. 1281–1298 . angiographic. If examination of the recently. or severe bleeding location. or (for haemorrhoidal bleed- tive therapy to superselective embolization (grade C ing) anoscopic techniques. Surgical intervention is evidence). and the order in which the stantial mortality rate. video capsule However. 157 Except in fulminant cases. including ventional radiologists have switched from vasoconstric. FRIEDMAN successfully as a single bolus intra-arterial injection to investigations are undertaken often depends on local stop lower gastrointestinal bleeding. 155–168 Embolotherapy has a number of distinct advantages over local vasocon- Surgery strictive therapy. As a result. endoscopic. treatment of non-occlusive Angiography should be reserved for the patient who colonic ischaemia is supportive. 172–175 be less amenable to embolotherapy than is bleeding in Surgical intervention for lower gastrointestinal bleeding the left colon. remaining jejunum and ileum is desired. To 55–65% of the examined patients with gastrointestinal date. which allows endoscopic evaluation of the sion). enteroscopy. the presentation is fulminant. FARRELL & L. persistent or recurrent bleeding. Angiodysplasia is more difficult to treat is necessary in 18–25% of patients who require blood with embolization than is diverticular bleeding and has transfusion (grade B evidence). with for a Meckel’s diverticulum may be appropriate in a rate of clinical success (cessation of bleeding) between young patients presenting with otherwise unexplained 44 and 91% and without major ischaemic complica. many inter. and most cases resolve has massive bleeding that precludes colonoscopy.153–155 These initial gastrointestinal endoscopy and colonoscopy are negat- complications deterred enthusiasm for the technique.1290 J. Most have intermittent bleeding or can Despite a dearth of comparative studies.e.177  2005 Blackwell Publishing Ltd. required when haemodynamic instability persists The location and aetiology of bleeding have important despite aggressive resuscitation. ive. vasopressin infu. The ing. and even those with prolonged bleeding. 170 A radionuclide scan superselective lower gastrointestinal embolization. despite its serious shortcomings.171 tions (grade B evidence). 7–40% of atherosclerosis. has spontaneously within several days to weeks.152 availability and expertise (grade C evidence).12.169. and some patients who are felt to source.142. dence).

192 A reliable resection.6% for patients hospitalized if segmental resection of the colon is to be successful. 145. although the number of patients studied was gastrointestinal bleeding12. 175. Aliment Pharmacol Ther 21. segmental those in whom lower gastrointestinal bleeding devel- resection based solely on tagged red blood cell scan oped following hospital admission (grade B evidence). 37%) (grade B evidence)145. 172–175.179 reasons. mortality rates as (grade B evidence). is an important OF LOWER GASTROINTESTINAL BLEEDING risk factor for postoperative mortality. 184.9% in those over 89 years) (grade B whom bleeding occurs during a hospitalization for other evidence). probably by PREDICTING OUTCOME AND RECURRENCE association with increase comorbidity. 189 The rebleeding rate following blind limited • Hypotension and shock despite resuscitation resection has been as high as 33%. and. 9. push enteroscopy.6 low as 5–10% have been reported for total abdominal A number of studies have proposed clinical prognostic colectomy (grade B evidence). 191 Although aged 70–79 years. complications. 186. 189 Mortality can criteria to distinguish patients with a high and a low also be more in patients who undergo a blind limited risk of recurrent haemorrhage. with lower gastrointestinal haemorrhage and 23. with a negative angiographic result (grade B evi- despite improved methods to localize the bleeding site dence). 180–186 Of 49 patients who transfused blood.145. bleeding in terms of risk of recurrent bleeding. only 25% of patients evidence). 19% at 3 years.6 A bleeding source has clearly been identified and in whom population-based study of patients enrolled in a health more conservative therapies have failed. 190 In one study. diverticular bleeding associated with substantial rates of rebleeding (as resolves spontaneously in over 75% of patients (grade B high as 33%) and mortality (33–57%) (grade B evidence).183. 189 Comparison of blind limited resec. mortality  2005 Blackwell Publishing Ltd. following the primary episode and in up to 50% the overall mortality rate was 27% (grade B evi. and When angiography is successful in localizing the angiography bleeding site. 8.6. radionuclide imaging.184.184 These data support • Continued bleeding (>6 U of packed red blood cells transfused) the importance of pursuing an aggressive approach to and lack of diagnosis (bleeding source) despite emergency preoperative localization of the bleeding source. limited intestinal resection has resulted • Active bleeding from a segmental gastrointestinal lesion that is amenable to cure or permanent hemostasis by surgery in significantly lower morbidity rates than did surgery • The patient is an emergency surgical candidate without a con in historic controls without angiographic localization traindicating comorbidity and with a reasonable life expectancy (8. and 12. 191. 183. in most series lower gastrointestinal bleeding Surgery should be considered in patients in whom a per se has uncommonly been the cause of death. with rates as high as 30–57% (grade B predictive model that can accurately forecast the evidence).7.187 In another report.189 that permit segmental rather than subtotal colectomy (grade B evidence).1% for Blind segmental resection of the colon. the rate of recurrent bleeding is 9% at 1 year. and 25% at 4 years 33% (grade B evidence). REVIEW: THE MANAGEMENT OF LOWER GI BLEEDING 1291 Table 3.6% vs. following a second episode of bleeding (grade B dence). need for tality rates that are similar if not higher for limited therapeutic intervention. outcome of an episode of acute lower gastrointestinal tion with total abdominal colectomy has shown mor.175. Indications for emergency surgery for severe lower resection. 184 small. The post-opera- tive mortality rate in patients who undergo surgery for Mortality rates for lower gastrointestinal bleeding are less colorectal cancer increases with age (3.6 localization.188 However. Accurate maintenance organization in the USA reported an preoperative localization of the bleeding site is essential in-hospital mortality rate of 3. 176.7% in patients than 5% (Grade B Evidence). 53 For patients with a discharge diagnosis who underwent a total abdominal colectomy for of diverticular bleeding who did not require definitive massive lower intestinal bleeding survived without therapy. 1281–1298 . importantly.50. and the mortality rate was a formidable 10% at 2 years. the rebleeding rate over a 1-year follow-up period was 14% after segmental colectomy directed by The overall operative mortality rate for emergency angiography and 42% after blind segmental colectomy surgery for lower gastrointestinal bleeding is 10%. 145. colonoscopy.12 The majority of patients require <4 U of evidence).8% in patients aged 80 to the highest mortality rates are reported for patients in 89 years.12. and emergency subtotal colectomy are When managed conservatively. 49. Bleeding recurs in 14–38% of cases underwent total abdominal colectomy in one study. 178 Age.

1292 J.191 MLR. 73 and 70%. lower gastrointestinal haemorrhage. Aliment Pharmacol Ther 21. was been suggested. a for severe lower gastrointestinal bleeding were an initial property that may explain in part the higher predictive haematocrit value <35%. 41%. and for endoscopic. 46%) and similar to department (grade B evidence).192 A hospital. elevated prothrombin time. ANN performed well A more recent prospective study aimed to identify risk in predicting death (97%). A different type of study investigated the use of tive models exist. presence of abnormal vital accuracy of ANN-based prediction models (grade B signs (systolic blood pressure <100 mmHg or heart rate evidence). in contrast to dence). and a direct risk and those at low risk of adverse in-hospital outcome comparison was made with MLR in patients admitted (recurrent haemorrhage. such as a visible vessel or dence). Whereas the presence of endoscopic severe lower gastrointestinal bleeding (grade B evi. further decrease in haematocrit value of hospitalization and the choice of early intervention for >20%) or readmission for lower gastrointestinal bleed. 1281–1298 . for recurrent acute lower gastrointestinal bleeding when applied at bleeding 89% vs. Although most risk scores are derived on the per rectum associated with a systolic blood pressure basis of a minimalist approach. no numerical risk score artificial neural network (ANN) in predicting clinical has been developed and validated to predict the outcome in patients admitted to the hospital with acute outcome of patients with acute lower gastrointestinal lower gastrointestinal bleeding. severe superior to the MLR model (70. computer-based decision <100 mmHg or heart rate greater than 100/min or support systems such as ANN have the ability to process transfusion of >2 U of blood. lower gastrointestinal bleeding occurs  2005 Blackwell Publishing Ltd. During external validation. In this study. systolic blood pressure of <115 mmHg. the presence of a clean-based ulcer factors predictive of severe lower gastrointestinal bleed. bleeding per rectum Although not as common as upper gastrointesti- during the first 4 h of evaluation.196 Additional or decrease in haematocrit value of >20%) and/or studies are needed before these clinical and endoscopic recurrent bleeding after 24 h of stability (additional criteria can be used to determine the need for in-patient transfusion. multiple logistic regression (MLR) models were con- The BLEED (ongoing bleeding. J. However. The ANN model and bleeding. the point of initial evaluation in the emergency or surgical intervention 96% vs. S. syncope. aspirin use and more nal bleeding. erratic mental typically are available during patient triage. and. The ANN acute lower gastrointestinal bleeding into those at high models then were validated externally. within a diverticulum may indicate a low risk of ing. respect- gastrointestinal bleeding was defined as gross blood ively). need for surgery to control with acute lower gastrointestinal bleeding to another haemorrhage.195 >100/min) 1 h after initial medical evaluation and Finally. The predictive accuracy of ANN was signifi- second prospective study by the investigators who cantly better than that of the BLEED classification devised the BLEED classification system found that it system (predictive accuracy in the internal validation could predict outcome in patients hospitalized with group for death was 87% vs.194 acute upper gastrointestinal bleeding. factors for severe lower gastrointestinal bleeding and for and the need for intervention (94%) and it was clearly important adverse outcomes. Independent correlates of severe bleeding were an initial heart rate of >100/ CONCLUSION min. ing within 1 week of discharge. including death. low systolic blood structed by using 26 non-endoscopic variables that pressure. unstable comorbid disease) classification system models were trained and then internally validated with has been proposed as a means of triaging patients with patient data that were collected prospectively. 21%. the predictive value of endoscopic findings in gross blood on initial rectal examination. The main the management of lower gastrointestinal bleeding has predictor of an adverse outcome. Independent risk factors a large amount of clinical information in a short time. to date. FRIEDMAN would be extremely useful for triaging patients to than two active comorbid conditions (grade B evi- appropriate levels of care. The ANN status. radiologic. Severe bleeding was defined as continued bleeding recurrent haemorrhage and permit early discharge within the first 24 h (transfusion of >2 U of blood and/ from the hospital (grade C evidence). and death) (grade B evidence). nontender abdominal examination. recurrent bleeding (93%). is a reliable marker of severe diverticular A similar retrospective study sought to identify clinical haemorrhage.193 adherent clot. stigmata of recent bleeding. FARRELL & L. few such predic.

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