GASTROINTESTINAL BLEEDING, LOWER   32A

A 53-year-old man comes to the emergency department with a 3-hour history of bright red blood per rectum. The man states that he had been feeling well until 3 hours before when he had the sudden urge to defecate and passed a large amount of bright red blood that seemed to fill the toilet bowl. After the initial episode, he passed similar amounts of blood mixed with stool four more times. He is feeling lightheaded but denies abdominal pain, nausea, vomiting, hematemesis, and melena. He had a similar but less severe episode some years ago that resolved quickly without treatment. His medical history includes diverticulosis coli, diagnosed on a prior computed tomography scan. On physical examination, his heart rate is 130 beats/min.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Hematochezia (recurrent episodes); no melena; painless; history of diverticulosis coli and prior episode of self-limited bleeding; symptoms and signs of volume depletion (lightheadedness, tachycardia)

How to think through: Gastrointestinal (GI) bleeding is common, and rapid initial triage is essential. What single feature in the case indicates the need for urgent management, and what is your first priority? (The heart rate of 130 beats/min indicates hypovolemia; rapid intravenous [IV] access is needed.) Would a normal hematocrit reassure you that a hemorrhage is insignificant? (No. The hematocrit in acute blood loss is often normal.) Are lower GI sources of blood loss more or less common than upper GI sources? Do they generally present higher or lower risk of death? (Lower GI sources are less common and generally less morbid.) What features make a lower GI source more likely in this case? (Bright red blood; history of diverticulosis coli.) What are the common causes of lower GI bleeding, and which of these fit with the data in this case? Would you assess risk factors for upper GI bleeding as well? (Yes. A brisk upper GI bleed may appear as red blood per rectum.) If hematochezia continues with persistent tachycardia despite transfusions, what are further diagnostic and treatment options? (Rapid purge colonoscopy and angiography and embolization by interventional radiology.) Is intervention typically needed in lower GI bleeding? (No. The majority of lower GI bleeds stop spontaneously. Supportive care and subsequent colonoscopy are the more common course.)

GASTROINTESTINAL BLEEDING, LOWER   32B

What are the essentials of diagnosis and general considerations regarding lower gastrointestinal bleeding?

Essentials of Diagnosis

Hematochezia is usually present, although 10% of hematochezia is caused by an upper GI source.

Stable patients can be evaluated by colonoscopy.

Massive active bleeding calls for evaluation with sigmoidoscopy, upper endoscopy, angiography, or nuclear bleeding scan.

General Considerations

Lower GI bleeding is defined as that arising below the ligament of Treitz (i.e., small intestine or colon; ≤95% of cases arise in the colon).

Lower GI bleeding is less common than upper GI bleeding and tends to be more benign.

Spontaneous cessation occurs in more than 85%; the hospital mortality rate is less than 4%.

The most common causes in patients younger than age 50 years are infectious colitis, anorectal disease, and inflammatory bowel disease.

The most common causes in patients older than age 50 years are diverticulosis coli (50%), colonic vascular ectasias, neoplasms, ischemia, varices, and ulcers.

In 20% of cases, no source of bleeding can be identified.

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