Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 2, 2003, pp. 151-155

Indian Journal of Surgery, Vol. 65, No. 2, March-April, 2003, pp. 151-155

Review Article

Lower gastrointestinal bleeding

C. Khandelwal

Department of Gastrointestinal Surgery, IGIMS, Sekhpura, Patna - 800 001
Address for correspondence Dr. (Prof.) C. Khandelwal, 6, Nehru Nagar, Patna-800 013, E-mail : drkhandelwal@hotmail.com

Paper Received: March 2002, Paper Accepted: November 2002. Source of Support: Nil. Delivered as part of CME during ASICON 2001.

Code Number: is03025

KEYWORDS: Bleeding, lower gastrointestinal, therapy

How to cite this article: Khandelwal C. Lower gastrointestinal bleeding. Indian J Surg 2003;65:151-5.

Lower gastrointestinal bleeding (LGB) means bleeding from sites distal to the ligament of Treitz and presents as rectal bleeding. This rectal bleeding may be overt or occult, and overt bleeding can be acute, massive or chronic. Mortality for LGB is around 11% overall and up to 21% for the acute massive category.¹

DIAGNOSTIC EVALUATION

A thorough clinical examination is necessary in all patients. Painless bleeding in an elderly man is often due to diverticular disease or vascular malformations. Mild to moderate pain with or without fever may be due to ischaemic colitis, infectious diarrhea or due to inflammatory bowel disease. Since the incidence of patients with HIV infection is on the rise, a possibility that the bleeding may be due to cytomegalovirus infection should be kept in mind, particularly in the young.²

The colour of the stool or the type of manifestation gives an idea about the source and rapidity of bleeding.

Manifestation	Likely Upper G.I.	Likely lower G.I.
Haematemesis	Assured	Ruled out
Malaena (Black shiny stool)	Probable	Possible
Haematochezia Bright red Maroon blood clot	Unlikely	Highly probable Distal colon Proximal colon / small bowel
Blood-streaked stool	Ruled out	Assured
Occult Blood	Possible	Possible

To start with, an upper GI bleed, which in nearly 20% patients presents as per rectal bleeding, must be excluded. Placement of a nasogastric tube can help in providing information. If the nasogastric tube contains no blood but contains bile, it almost certainly rules out upper G.I. bleed. However, an upper G.I. endoscopy must be performed additionally to rule out a lesion. Haematochezia free of stool is typical of anorectal pathology. A flexible sigmoidoscopy should be done, which can establish the diagnosis of ulcerative colitis, diverticulitis, radiation proctocolitis, solitary rectal ulcer syndrome, haemorrhoids and tumours.

Common Causes of lower G.I. Bleeding
Common Causes	Less Common Causes
Colonic Vascular ectasias Diverticula Neoplasm Benign anorectal causes Haemorrhoids Fissures Fistula Inflammatory Bowel Disease Ulcerative Colitis Crohn's disease Mesenterie vascular insufficiency Ischaemic Colitis Radiation Colitis Infectious Colitis	Meckel's diverticulum Vasculitides Small Intestinal causes Vascular ectasias Diverticula Ulceration Intussusception Endometriosis Bleeding in runners Dieulafoy's lesion Visceral arterial aneurysm Brown bowel syndrome Cytomegalovirus Colitis Pancreatic pseudocyst Neoplasm Carcinoid Lymphomas Sarcomas Haemangiomas Solitary Rectal Ulcer Syndrome Diversion Colitis

At different ages, the common causes of massive bleeding are different

(A) Adolescent and young

• Meckel's diverticula
• Inflammatory Bowel Disease
• Polyps

(B) Up to 60 yrs of age

• Diverticula
• IBD
• Neoplasm

(C) Above 60 yrs of age

• Angiodysplasia
• Diverticula
• Neoplasm

However, in India the common causes of LGB are different and it occurs in a younger population.

• Non-specific ulcers 30%
  Shallow punched out, 0.5 to 1 cm, at distal ileum and right colon, little inflammation
• Enteric Ulcers 15%
• Tubercular Ulcers 6%
• Neoplasm 6%
• Amoebic ulcers 6%
• Angiodysplasia 6%
• Others (Ischaemic bowel disease 31%
  Meckels' diverticula, Solitary rectal ulcer etc.)

In comparison with the West, in the Indian experience, patients are younger, localization is possible in a majority of patients, mortality is lower and re-bleed rate is only 4%³.

Any patient coming with massive lower G.I. bleed should first be resuscitated with an isotonic crystalloid fluid and blood; preferably with two I.V. catheters to maintain haemodynamic stability. History and physical exam including rectal examination and proctosigmoidoscopy should be done. Hb%, PCV, coagulation profile, blood group and L.F.T. should be done urgently. A simple nasogastric tube helps in excluding upper G.I. bleed. Severity and activity of the bleeding may be classified as follows

(a) Major or Massive ongoing only 10-20% cases
(b) Major but self-limiting 75% cases
(c) Minor self-limiting

For massive LGB, the choices available are

1. Urgent Colonoscopy
2. Nuclear Scintigraphy
3. Angiography
4. Urgent surgery: If bleeding continues and 3-5 units of blood transfusion are needed in 24 hours.

COLONOSCOPY

Colonoscopy is the most convenient and effective preliminary procedure⁴. Actual visualization during acute episode is uncommon because the view is poor. After colonic lavage/purge, colonoscopic examination may localize a bleeding point. Presence of anorectal and distal colonic lesions does not necessarily rule out the presence of a more proximal source of bleeding. A search of relevant literature does not specify an ideal time for colonoscopy. While some authors advocate early colonoscopy in an unprepared bowel, others advise a more expectant approach. In a study on colonoscopy without any bowel preparation⁵ it was concluded that the procedure was safe and accurate and allowed the performance of therapeutic procedures with minimal complications. Accurate localization of lesions was possible in 97% of patients. Prior preparation of the gut has not been associated with reactivation of bleeding from the colon.⁶ Today colonoscopy is the diagnostic investigation of choice.⁷ However, the questions about its timing and the need for bowel preparation remain unanswered.

Another method of colonoscopy called virtual colonoscopy (includes CT and MR colography) seems promising for detection of cancer and is non -invasive but its results are inferior to colonoscopy.⁸ Argon beam, electrocautery, laser, ablation, injection sclerotherapy, haemoclip etc. may be used to stop the acute haemorrhage.

NUCLEAR SCINTIGRAPHY

Selective visceral angiography and radioisotope scanning may be viewed as complementary investigations in the preoperative localization of a bleeding site.⁹ 99mTc-radiolabelled red blood cell scanning has a high predictive value. The long intravascular half-life of labelled red cells allows repeat scanning and increases the probability of isolating those lesions that bleed intermittently. 99mTc-radiolabelled sulphur colloid does not localize the exact bleeding site but can detect bleeding (active) as slow as 0.1-0.5 ml/minute. Its advantages include accuracy, safety, its non-invasive character, freedom from contrast-related problems and a low cost. At the moment, radioisotope scanning is limited to screening prior to angiography and it has no therapeutic value.

ANGIOGRAPHY

Angiography can detect a bleeding source if the rate of bleeding is 0.5-1 ml/minute. Its localization is accurate and it also offers therapeutic options (embolization and the use of therapeutic drugs such as vasopressin). Selective visceral angiography can be very useful in localizing the site during the acute episode and also many patients are suitable for highly selective mesenteric vessel embolization¹⁰ (with gelfoam, wire, coil, blood clot, etc.). There are a few associated complications of the procedure and therefore angiography can be restricted to those in whom bleeding continues. To improve the results of angiography, some authors have advocated the use of thrombolytics, anticoagulants or vasodilators prior to angiography.¹¹ The pre-operative localization of bleeding may facilitate minimal access surgery (for example, laparoscopically assisted colectomy or Meckel's diverticulectomy).

TREATMENT

Active treatment is necessary for a small group of patients because in the majority, bleeding stops spontaneously. The treatment options available are therapeutic colonoscopy or angiography and surgery.

The various colonoscopic therapeutic modalities currently in use are injection, laser coagulation electrocautery and "heater probe". Approximately 12% of patients are amenable to colonoscopic treatment.¹² The complications associated with colonoscopic treatment varied from 1.3% to 3%.^5,12 Bipolar coagulation is safer than monopolar electrocoagulation. It is not clear which of the several methods is the best. Also, colonoscopic therapy is usually not a definitive treatment modality; it merely tides over the critical period so that definitive surgical treatment can be undertaken when the patient is in a relatively stable condition.

Treatment along with the use of angiography (using vasopressin or embolization) is on the rise in the management of lower GI bleeding. Haemostasis can be achieved with embolization in 71% of patients and only in 10% the bleeding cannot be controlled. The procedure may not be technically feasible in 19% of patients¹⁰. Vasopressin therapy has not been compared with embolization, though angiographic embolization is usually done for patients with continuing bleeding prior to a surgical intervention so as to allow the patients to be in a better general condition.

Surgical treatment is reserved for those who continue to bleed or re-bleed after initial cessation (either spontaneously or following an intervention). At operation, identifiable lesions, even if they are not bleeding (potential bleeding sites) such as a carcinoma or Meckel's diverticulum, should be resected. For patients with continuing bleeding from an unidentified source, a blind subtotal colectomy should be done.

DIVERTICULOSIS

diverticuli are usually found in the distal colon, in 90% of the patients they are confined to the sigmoid colon only. 50% of the population above 60 years has diverticuli in Western world but only 3% to 5% bleed. Up to 70% of bleeding diverticula are situated at an unusual proximal site. Bleeding is usually self-limiting and only less than 25% re-bleed. Endoscopic therapy, as mentioned earlier, has a high success rate. Occasionally, a "rebleed" may require surgery which may be a segmental or subtotal colectomy. Jejunal diverticular disease should also be looked for.

COLONIC VASCULAR ECTASIA / ANGIODYSPLASIA / A V MALFORMATION

25% of people over 60 years of age have asymptomatic colonic vascular ectasia. Mostly found in the caecum and proximal ascending colon but only 10% will bleed. Bleeding is usually chronic and recurrent but occasionally may present as an acute or a massive bleed. 90% stop spontaneously but will recur in 85%. There is a well-recognized association between angiodysplasia and aortic stenosis and replacement of the stenotic valve has been reported to stop G.I. bleed in over 90% of patients. Echocardiography should therefore be a part of the investigations in such cases. Angiodysplasia of the right colon frequently occurs with co-existing jejunal or ileal malformations and it is prudent to also perform upper G.I. endoscopy and per-operative enteroscopy. If an arteriovenous cause of the bleeding is found, argon beam ablation, electro-cautery, laser ablation or injection sclerotherapy may be used to stop the acute haemorrhage. Approximately 20% of patients undergoing surgery for angiodysplasia will re-bleed.

NEOPLASIA

Both benign adenomata and colorectal cancers commonly cause bleeding. Characteristically, cancers in the caecum and to a lesser extent, in the right colon present in this way.

For an advanced colorectal cancer that is bleeding, laser ablation is useful. Endoscopic electrocoagulation may be attempted for bleeding below a peritoneal reflection. External radiotherapy at a reduced dose may also be tried. Bleeding from radiation proctitis/colitis may be controlled by laser or by bipolar electrocoagulation. Topical formalin has also been successfully used.

OBSCURE BLEEDING

In most patients the cause of an acute significant bleed is easy to determine, in some it is not. Repeated upper and lower GI endoscopy should be done with recurrent lower G.I. bleed; pan-endoscopy, small and large bowel radiological studies, radio-labelled RBC scan, echocardiography (to detect aortic stenosis), selective visceral angiography and per-operative enteroscopy may be required in that order. Enteroclysis (double contrast) picks up lesions in 10% to 20% patients in whom barium meal has failed.

For recurrent obscure bleeding, an approach being advocated recently, is the use of anti-coagulants, vasodilators or thrombolytic agents to reactivate or augment the bleeding followed by a nuclear scan or angiography. However, the diagnostic yield of this approach is only 20%.¹³

Those who are actively bleeding and multiple attempts at preoperative localization have failed, may require surgery. If an operation is carried out, it should be as the final diagnostic and therapeutic step. During laparotomy, a colonoscope may be passed both through the mouth and anally to perform pan-endoscopy. During peroperative enteroscopy the operating and theatre lights are dimmed to allow transillumination of the bowel and transluminal inspection. In patients with profuse colorectal bleeding, the view during peranal colonoscopy is often obscured by blood. A terminal ileal enterotomy allows retrograde small bowel inspection and a prograde lavage of colon. An excellent examination of the entire colon and rectum can be achieved after advancement of colonoscope through the ileocaecal valve or via a caecostomy. Transillumination of bowel wall can also be done with a fibreoptic light source in a darkened operation theatre. There should be proper hydration to fill thin-walled veins to detect angiodysplasia. Multiple enterostomies must not be made. In our experience, most were young patients, usually with a non-specific ulcer in the small bowel near the terminal ileum that remained undiagnosed till laparotomy was executed.

REFERENCES

1. Leitman IM, Paull DE, Shires GT III, Evaluation and management of massive lower gastrointestinal haemorrhage. Ann Surg 1989;209:175-80.
2. Bini E J, Weinshel EH, Fal Kentstein DB. Risk factors for recurrent bleeding and mortality in human immunodeficiency virus infected patients with acute lower GI hemorrhage. Gastrointest Endosco 1999;748-53.
3. Govil D, Sahni P. Lower Gastrointestinal Haemorrhage. GI Surgery Annual Vol 1994;93-103.
4. Richter JM, Christensen MR, Kaplan LM, Nishioka NS. Effectiveness of current technology in the diagnosis and management of lower gastrointestinal haemorrhage. Gastrointest Endosc 1995;41:93-8.
5. Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: The initial test for acute lower gastrointestinal bleeding. Am Surg 1998;64:723-53.
6. Bloomfield RS, Rockey DC. Diagnosis and management of lower gastrointestinal bleeding. Cur Opin Gastroenterol 2000;16:89-97.
7. Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. Americal College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol 1998;93:1202-8.
8. Rex DK, Vining D, Kopecky KK. An initial experience with screening for colon polyps using spiral CT with and without CT colography (virtual colonoscopy). Gastrointest Endosc 1999;50:309-13.
9. Nicholson ML, Neoptolemos JP, Sharp JF, Watkin EM, Fossard DP. Localization of lower gastrointestinal bleeding using in vivo technetium-99m-labelled red blood cell scintigraphy. Br J Surg 1989;76:358-61.
10. Nicholson AA, Ettles DF, Hartley SE, Curzon I, Lee PWR, Duthie, GS et al. Transcatheter. Coil embolotherapy: a safe and effective option for major colonic haemorrhage. Gut 1998;43:79-84.
11. Peck DJ, McLoughlin RF, Hughson MN, Rankin RN. Percutaneous embolotherapy of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 1989;9:747-51.
12. Zuckerman GR, Prakash C. Acute lower intestinal bleeding: Part I: Clinical presentation and diagnosis. Gastrointest Endosc 1998;48:606-17.
13. Malden ES, Hicks ME, Royal HD, Aliperti G, Allen BT, Picus D. Recurrent gastrointestinal bleeding: Use of thrombolysis with anticoagulation in diagnosis. Radiology 1998;207:147-51.

Copyright 2003 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com