Gastrointest Interv 2018;7:100–105

Gastrointestinal Intervention
journal homepage: www.gi-intervention.org

Review Article
Clinical assessment and treatment algorithm for lower
gastrointestinal bleeding
Soo-Kyung Park*

A B S T R A C T

Lower gastrointestinal bleeding (LGIB) is diagnosed in 20% to 30% of all patients presenting with major gastrointestinal (GI) bleeding. Although most
patients with acute LGIB stop bleeding spontaneously and have favorable outcomes, morbidity and mortality ranges from 2% to 4%, and is higher
in older patients and those with comorbid medical conditions. Common etiologies of LGIB are diverticular bleeding, ischemic colitis, angioectasia
bleeding and hemorrhoid. Patients presenting with acute severe hematochezia should undergo a focused evaluation simultaneous with hemodynamic
resuscitation. An upper GI bleeding source must be excluded in patients with hematochezia and hemodynamic instability. Colonoscopy following a
colon preparation is the initial test of choice in most patients presenting with acute hematochezia and hemodynamic stability.
Copyright © 2018, Society of Gastrointestinal Intervention.

Keywords: Hemorrhage; Intestines; Therapeutics

Introduction
Lower gastrointestinal bleeding (LGIB) is diagnosed in 20%
to 30% of all patients presenting with major gastrointestinal
(GI) bleeding.1,2 Compared with acute upper GI bleeding (UGIB)
patients, patients with LGIB tend to present with a higher hemo-
globin level and are less likely to develop hypotensive shock or
require blood transfusions.3 Although most patients with acute
LGIB stop bleeding spontaneously and have favorable outcomes,
morbidity and mortality ranges from 2% to 4%,4,5 and is higher in
older patients and those with comorbid medical conditions.6
Definition of LGIB
LGIB has been defined as bleeding originating distal to the
ligament of Treitz. However, since the advent of capsule endos-
copy and enteroscopy, small-bowel sources have been placed in
the category of midgut bleeding from the small intestine (middle
GI bleeding), which is distinct from colonic bleeding in terms of
presentation, management, and outcomes.7 Thus, the new defini-
tion of LGIB has been proposed as bleeding from a source distal
to the ileocecal valve, with hematochezia originating from either
the colon or the rectum.8 Acute LGIB is defined as recent bleeding
(< 3 days) that may result in hemodynamic instability, anemia,
and/or the need for blood transfusion. Chronic LGIB is the pas-
sage of blood per rectum over a period of several days or longer,
and usually implies intermittent or slow loss of blood.3
Etiologies of LGIB
Diverticular bleeding
Diverticular bleeding accounts for 30% to 65% of acute LGIB
episodes (Table 1). Colon diverticula are present in up to 30% of
patients aged ≥ 50 years, with the prevalence increasing to ap-
proximately 60% in those aged ≥ 80 years in studies from West-
ern countries.9 In Korea, the prevalence of colonic diverticulosis
has increased to 12% in conjunction with the adoption of Western
dietary habits, extension of lifespan, and advances in diagnostic
modalities.10 Nonsteroidal anti-inflammatory drugs (NSAIDs) in-
crease the risk for diverticular bleeding, while hypertension and
anticoagulation may also contribute to severe bleeding.11,12 The
clinical presentation of diverticular bleeding is characterized by
painless hematochezia. Bleeding resolves spontaneously in 75%

Division of Gastroenterology, Department of Internal Medicine and Gastrointestinal Cancer, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
Received July 9, 2018; Revised August 10, 2018; Accepted August 10, 2018
* Corresponding author. Division of Gastroenterology, Department of Internal Medicine and Gastrointestinal Cancer, Kangbuk Samsung Hospital, Sungkyunkwan University
School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 03181, Korea.
E-mail address: sk0103.park@samsung.com (S.K. Park). ORCID: https://orcid.org/0000-0001-8822-9632

pISSN 2213-1795 eISSN 2213-1809 https://doi.org/10.18528/gii180024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Soo-Kyung Park / Lower GI bleeding 101

to 80% of patients, but recurs in 25% to 40% within 4 years.4 in mesenteric blood flow secondary to hypoperfusion, vasospasm,
The diagnosis of diverticular hemorrhage is presumptive in most or occlusion of the mesenteric vasculature. Ischemic colitis mani-
patients, and is based on the presence of colon diverticula and fests with a wide spectrum of injuries, including reversible colopa-
the absence of another obvious source of LGIB. A definitive diag- thy (subepithelial hemorrhage and edema), transient colitis, chron-
nosis is made in approximately 22% of patients who have active ic colitis, stricture, gangrene, and fulminant universal colitis. The
bleeding or high-risk stigmata of a visible vessel or clot on colo- typical locations affected by nonocclusive colon ischemia are the
noscopy.13 After endoscopic treatment, early rebleeding is uncom- splenic flexure and rectosigmoid junction; the rectum usually is
mon.14,15 Late rebleeding may occur from diverticula at a location spared, because of its dual blood supply.18 Patients with ischemic
different from that of the index bleed. colitis often have underlying cardiovascular disease and present
with hypotension or hypovolemia, which results in mesenteric
Ischemic colitis hypoperfusion and vasoconstriction. The clinical presentation of
ischemic colitis is cramping abdominal pain over the segment of
Ischemic colitis is the underlying etiology in 1% to 19% of pa- colon involved, followed by a short course of bloody diarrhea.19
tients with LGIB and most commonly affects elderly patients.16,17 Typical endoscopic findings are submucosal hemorrhage and
Ischemic colitis results from a sudden, often temporary, reduction ulcerations in the colon and a single linear ulcer that runs along
the longitudinal axis of the colon on the antimesenteric border
(Fig. 1A, 1B).20 Angiography should be considered in patients with
Table 1 Causes of Acute Lower Gastrointestinal Bleeding severe ischemic colitis or right-side involvement, when there is
suspicion for an underlying thromboembolism or concomitant
Cause Cases (%) mesenteric ischemia involving the small bowel.21 The majority of
Diverticulosis 30–65 patients diagnosed with ischemic colitis show improvements with
conservative management including intravenous hydration and
Ischemic colitis 4–20
correction of the underlying etiology, although some with more
Hemorrhoids 4–20 severe disease require antimicrobials and/or surgical interven-
Angioectasias 4–15 tion.21
Colitis, other 3–15
Angioectasia
Colorectal polyps or neoplasms 2–15
Postpolypectomy bleeding 2–7 Angioectasias, also named angiodysplasias are caused by
Inflammatory bowel disease 3–5 degenerative changes and chronic intermittent low-grade ob-
struction in the submucosal vessels.22 The prevalence of colon an-
Rectal ulcer 0–8
gioectasia is 3% to 15% in patients with LGIB.17 The presence of
Data from the article of Gralnek et al (N Engl J Med. 2017;376:1054-63).35

A B

C D Fig. 1. Ischemic colitis at sigmoid colon (A, B).

Angioectasias at ascending colon (C, D)
102 Gastrointestinal Intervention 2018 7(3), 100–105
colonic angioectasia is associated with valvular heart disease, liver
cirrhosis, and chronic renal failure, and risk factors for bleeding
include advanced age, comorbidities, the presence of multiple an-
gioectasias, and the use of anticoagulants or antiplatelet agents.23
Patients can present with occult bleeding, melena, or painless
intermittent hematochezia.24 Colonoscopy has a sensitivity of 80%
for the detection of angioectasias, and typical endoscopic findings
are red, flat lesions, ranging in size from 2 mm to several centi-
meters, with ectatic blood vessels radiating from a central feeding
vessel, predominantly in the cecum and the ascending colon (Fig.
1C, 1D).22
Hemorrhoids
The prevalence of hemorrhoidal bleeding has been reported as
2% to 64% in patients presenting with hematochezia.4,17 Hemor-
rhoids are a plexus of dilated arteriovenous vessels that arise from
the superior and inferior hemorrhoidal veins; these plexuses are
located in the submucosa of the distal rectum and are classified as
internal or external, based on their location relative to the dentate
line.25 Patients typically present with painless, intermittent, scant
hematochezia characterized by bright red blood on the toilet pa-
per, coating the stool, or dripping into the toilet bowl.
Colorectal neoplasia
Colorectal neoplasia accounts for up to 17% of all etiologies
in patients with LGIB and presents more commonly with occult
bleeding.4,26 In addition to LGIB, symptoms of bowel habit chang-
es and weight loss should raise suspicion for colorectal neoplasia
and prompt colonoscopy should be performed. LGIB associated
with colorectal neoplasia usually results from surface ulcerations
A B
C D
of an advanced tumor. Patients with tumors in the right side of
the colon are more likely to present with occult blood loss and
iron deficiency anemia, whereas those with left-side tumors more
commonly present with hematochezia.25,26 Endoscopic treatment
for hemostasis is rarely required because bleeding from colorectal
neoplasia is slow in the majority of patients.25
NSAID use
NSAID use is associated with an increased risk of LGIB, in-
cluding diverticular bleeding.11 The prevalence of NSAID use is
reported to be as high as 86% in patients with LGIB.27 The mecha-
nisms involved in the induction of LGIB by NSAIDs are not well
understood and may include local mucosal trauma and platelet
inhibition in susceptible individuals as well as the concomitant
use of warfarin and other antiplatelet agents.28 Use of NSAIDs can
induce NSAID colopathy, which is characterized by colon ulcer-
ations and diaphragm-like strictures, predominantly located in the
terminal ileum and right side of the colon.28
Miscellaneous Etiologies
Post-polypectomy bleeding has been reported to account for
2% to 8% of acute LGIB.29 The initial assessment of the patient
presenting with presumed acute LGIB should include a focused
history including recent polypectomy (Fig. 2). Rectal ulcers have
been reported in 8% of patients who present with severe hema-
tochezia,30 and are an important cause of acute LGIB in patients
with critical illness such as end-stage renal disease on hemodialy-
sis, respiratory failure requiring mechanical ventilation, decom-
pensated cirrhosis, or malignancy.31 Endoscopic findings range
from clean-based ulcers (82%) to adherent clots (17%), non-
Fig. 2. Post-polypectomy bleeding. (A) Polyp at
ascending colon, (B) post-polypectomy ulcer, (C)
post-polypectomy bleeding at next day, (D) bleed-
ing control with clips.
 Soo-Kyung Park / Lower GI bleeding
bleeding visible vessels (33%), and active bleeding (50%).30 Early
rebleeding after endoscopic treatment has been reported in 44%
to 48% of patients, and a mortality rate of 33% to 48% has been
reported in patients with high-risk stigmata who have multiple
comorbidities.31
In radiation proctopathy, LGIB has been reported in 4% to
13% of patients. This disorder is caused by radiation-induced
endarteritis obliterans, which results in neovascularization and
telangiectasias in the rectum.26
Patients with inflammatory bowel disease commonly present
with LGIB. Clinically significant bleeding in Crohn’s disease is
more common in patients with colon involvement than in those
with isolated small-bowel disease.32
Management
Evaluation
A directed history-taking, physical examination, and labora-
tory evaluation should be performed at the time of patient pre-
sentation with the goal of determining the severity of bleeding, its
possible location, and etiology.33–35 The history obtained should
include the color, amount, frequency, and duration of bleeding
and any associated symptoms that may suggest a specific source
such as abdominal pain and diarrhea (colitis), and altered bowel
habits and weight loss (malignancy). In addition, a targeted his-
tory of medications that may influence bleeding risk (NSAIDs,
antiplatelet agents, and anticoagulants), prior bleeding episodes,
recent polypectomy, radiation therapy for prostate or pelvic
malignancies, inflammatory bowel disease, and risk factors for
colorectal cancer may be useful to determine the potential source
of bleeding and guide further management.34
The physical examination should include the measurement of
vital signs, and a cardiopulmonary, abdominal, and digital rectal
examination should also be performed. Initial laboratory studies
should include a complete blood count, serum electrolytes, and
coagulation studies, with blood typing and cross-matching.34,36
Hemodynamic resuscitation
Hematochezia associated with hemodynamic instability and/or
suspected ongoing bleeding should receive intravenous fluid re-
suscitation.37,38 In addition, some patients will require blood trans-
fusions. Large observational studies and a meta-analysis of three
small trials of UGIB suggest that blood transfusion compared with
no transfusion is associated with an increased risk of rebleeding
and possibly death.39,40 These findings are supported by results
of a large randomized trial of patients with UGIB that found that
a restrictive transfusion strategy with a transfusion threshold of
hemoglobin < 7 g/dL improved survival (95% vs 91%) and de-
creased rebleeding (10% vs 16%), when compared with a thresh-
old of 9 g/dL.39 Patients with massive bleeding, acute coronary
syndrome, symptomatic peripheral vascular disease, or a history
of cerebrovascular disease were excluded, and all patients under-
went upper endoscopy within 6 hours of presentation. Therefore,
patients with LGIB who have significant comorbid disease, mas-
sive, ongoing bleeding, or delayed therapeutic interventions may
benefit from a more lenient blood transfusion threshold (9 g/dL).
Severe hematochezia
Severe hematochezia associated with hemodynamic instabil-
ity should lead to consideration of a brisk UGIB source, especially
103
in at-risk patients such as those with a history of peptic ulcer
disease or liver disease with portal hypertension and those using
antiplatelet or anticoagulant medications.15,34,36 If suspicion for an
UGIB source is modest, nasogastric aspirate/lavage can be used
to assess possible UGIB.34,36 The nasogastric tube can be left in
place to facilitate subsequent colon preparation.13 If the likelihood
of UGIB is high, emergent esophagogastroduodenoscopy (EGD)
is the test of choice for the evaluation and management of high-
risk upper GI lesions, followed by colonoscopy after an upper GI
source is ruled out.41
Radiographic interventions should be considered in patients
with hemodynamically unstable and ongoing bleeding and are
therefore unlikely to tolerate bowel preparation and urgent colo-
noscopy. Angiography localizes a LGIB source in 25% to 70%
of exams.42,43 A systematic review found that super-selective an-
giographic embolization achieves immediate hemostasis in 40%
to 100% of cases of diverticular bleeding with a rebleeding rate
ranging from 0% to 50%.44 Because angiography relies on active
bleeding and has the potential for serious complications, it should
be reserved for patients with very brisk, ongoing bleeding.
Colonoscopy should be performed first in hemodynamically
stable patients with severe hematochezia.45 The main advantage of
colonoscopy is ability to perform a therapeutic intervention with
diagnosis of the underlying lesion.46 The diagnostic yield of colo-
noscopy ranges from 45% to 100% in LGIB and is significantly
higher than radiologic evaluation with a red blood cell scan and
angiography.47,48 It is important to carefully inspect the colonic
mucosa both on insertion and withdrawal, as culprit lesions often
bleed intermittently and may be missed when not actively bleed-
ing. The endoscopist should intubate the terminal ileum to rule
out proximal blood suggestive of a small bowel lesion. An adult
or pediatric colonoscope with a large working channel (at least 3.3
mm) should be used because the larger working channel facili-
tates suctioning of blood, clots, and residual stool, and allows for
the passage of large diameter (e.g., 10 Fr) endoscopic hemostasis
tools. In addition, the use of a water-jet irrigation device (foot
pedal controlled by the endoscopist) is recommended to facilitate
removal of adherent material and residue from the colonic mu-
cosa.
An urgent colonoscopy is recommended in the evaluation
of severe hematochezia and should be performed within 8 to 24
hours of admission.15,47 Early performance of colonoscopy in-
creases both its diagnostic yield and the likelihood of a therapeu-
tic intervention, and reduces the duration of hospitalization and
cost of care.15,47,49 However, there is no improvement in outcomes
of rebleeding or surgery after urgent colonoscopy.15,50
Colon preparation is important before colonoscopy to improve
visualization, increase the diagnostic yield, and reduce the risk of
perforation.34,36 Thus, once the patient is hemodynamically stable,
colonoscopy should be performed after adequate colon cleans-
ing, and unprepared colonoscopy/sigmoidoscopy is not recom-
mended. Polyethylene glycol-based solutions can be administered
orally at a rate of approximately 1 L every 30 to 45 minutes until
the effluent is free of fecal material.51 A nasogastric tube can be
considered to facilitate colon preparation in patients who are
intolerant of oral intake and are at low risk of aspiration.33 After
bowel preparation, colonoscopy should be performed within 1 to
2 hours.
Scant intermittent hematochezia
Chronic intermittent passage of small amounts of blood per
rectum is the most common pattern of LGIB and usually is caused
104 Gastrointestinal Intervention 2018 7(3), 100–105

Low GI bleeding

Clinical assessment, vital sign, laboratory test

Hemodynamic instability, signs and

Hemodynamically stable
symptoms of ongoing bleeding

Resuscitate with IV fluids and if indicated,

blood product transfusion, consider Severe Scant intermittent
Melena
management in intensive care unit hematochezia hematochezia

Remain > age 40 yr, < age 40 yr,

Consider
hemodynamically alarm symptom no alarm symptom EGD
NG tube
unstable /risk factor /risk factor

Positive aspirate
Radiographic Negative
or risk factor for Sigmoidoscopy Negative
intervention aspirate
UGI bleeding

Negative
Refractory
bleeding
4 6 L of PEG solution given over 3 4 hr

Surgery EGD Colonoscopy

Fig. 3. Treatment algorithm for lower gastrointestinal (GI) bleeding. IV, intravenous; NG, nasogastric; UGI, upper gastrointestinal; EGD, esophagogastroduodenos-
copy; PEG, polyethylene glycol.

by an anorectal or distal colon source of bleeding.52,53 A digital
rectal examination and flexible sigmoidoscopy may be sufficient
for the evaluation of average risk patients with minimal bright red
bleeding per rectum.54 The diagnostic yield of flexible sigmoidos-
copy ranges up to 58% in patients with LGIB, and colonoscopy
should be pursued in the absence of a definitive source of bleed-
ing on flexible sigmoidoscopy, patients aged > 50 years, the pres-
ence of iron deficiency anemia, risk factors for colorectal neopla-
sia, or alarm symptoms of weight loss or bowel habit changes.36,55
Melena
In the evaluation of melena, the majority of patients have
UGIB and EGD should be the initial test.41 However, melena also
may result from slow bleeding emanating from the colon or small
bowel. Therefore, if there are negative results on EGD, colonos-
copy should be performed. Persistent melena after negative results
with bidirectional endoscopy may warrant small-bowel endos-
copy for evaluation of occult GI bleeding.56
Conclusion
A management approach for patients presenting with acute
LGIB is outlined in Fig. 3. To summarize, patients presenting with
acute severe hematochezia should undergo a focused evaluation
simultaneous with hemodynamic resuscitation. A UGIB source
must be excluded in patients with hematochezia and hemody-
namic instability. Colonoscopy following a colon preparation is
the initial test of choice in most patients presenting with acute
hematochezia and hemodynamic stability.
Conflicts of Interest
No potential conflict of interest relevant to this article was re-
ported.
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Society of Gastrointestinal Intervention

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is a unique multidisciplinary society to encourage and facilitate

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between radiologists, surgeons and gastroenterologists.

Endoscopy Radiology Surgery

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gastrointestinal surgeons for multidisciplinary collaboration and interaction

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