GuidelineThe role of endoscopy in the patient with lower GI bleeding
Introduction
Lower GI bleeding (LGIB) is diagnosed in 20% to 30% of all patients presenting with major GI bleeding.4, 5, 6 The annual incidence of LGIB is 0.03%, and it increases 200-fold from the second to eighth decades of life.7, 8, 9 The mean age at presentation ranges from 63 to 77 years.9, 10 Approximately 35.7 per 100,000 adults in the United States are hospitalized for LGIB annually, and a full-time gastroenterologist manages more than 10 cases per year.8, 11, 12
Although blood loss from LGIB can range from trivial to massive and life-threatening, the majority of patients have self-limited bleeding and an uncomplicated hospitalization. Compared with acute upper GI bleeding (UGIB), patients with LGIB tend to present with a higher hemoglobin level and are less likely to develop hypotensive shock or require blood transfusions.6, 13 The mortality rate ranges from 2% to 4%8, 10, 14 and usually results from comorbidities and nosocomial infections.15 A recent epidemiologic study reported a decreased incidence of LGIB (41.8/100,000 in 2001 vs 35.7/100,000 in 2009; P = .02) and a lower age-adjusted and sex-adjusted case fatality rate (1.93% in 2001 vs 1.47% in 2009; P = .003) over the past decade.12
LGIB historically has been defined as bleeding that emanates from a source distal to the ligament of Treitz.1, 16 After the advent of deep enteroscopy, small-bowel sources have been placed in the category of midgut bleeding, and a new definition of LGIB has been proposed as bleeding from a source distal to the ileocecal valve.17, 18
Acute LGIB is defined as bleeding of recent duration (<3 days) that may result in hemodynamic instability, anemia, and/or the need for blood transfusion.13, 19, 20 Chronic LGIB is the passage of blood per rectum over a period of several days or longer and usually implies intermittent or slow loss of blood. Patients with chronic LGIB present with occult fecal blood, intermittent melena or maroon stools, or scant amounts of bright red blood per rectum.
Section snippets
Etiologies of LGIB
The most common etiologies of LGIB are shown in Table 2.
Management of LGIB
Algorithms for the management of LGIB are shown in Figures 1 and 2.
Endoscopic treatment of bleeding diverticula
Thermal contact modalities, including heater probe and bipolar coagulation, can be used alone or in combination with epinephrine injection for the treatment of bleeding colon diverticula. Epinephrine solution in a dilution of 1:10,000 or 1:20,000 is injected in aliquots of 1 mL to 2 mL at the site of active bleeding or around a nonbleeding visible vessel. An adherent clot, if present, may be guillotined by using a polypectomy snare. The visible vessel can be treated effectively by using a
Nonendoscopic treatment of acute LGIB
Mesenteric angiography with or without a preceding nuclear red blood cell scan is reserved for patients with severe bleeding who cannot be stabilized or prepped for a colonoscopy and for those who have failed endoscopic management. The multidetector row CT scan may be superior to the nuclear red blood cell scan for evaluation of LGIB. It decreases scan time, allows accurate acquisition of arterial images, and demonstrates contrast material extravasation into any portion of the GI tract.127 The
Recommendations
- 1.
We recommend colonoscopy in patients with occult GI bleeding. (⊕⊕⊕⊕)
- 2.
We recommend EGD in patients with occult GI bleeding if a bleeding source is not identified in the colon, especially in those patients with upper GI symptoms, iron deficiency anemia, or nonsteroidal anti-inflammatory drug use. (⊕⊕⊕○)
- 3.
We suggest small-bowel evaluation after negative EGD and colonoscopy results in patients with occult GI bleeding who have persistent anemia. (⊕⊕○○)
- 4.
We recommend colonoscopy for the evaluation of
Disclosures
The following authors disclosed a financial relationship relevant to this publication: Dr Saltzman, consultant to Beacon Endoscopy; Dr Khashab, consultant to Boston Scientific. All other authors disclosed no financial relationships relevant to this article.
References (132)
- et al.
ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding
Gastrointest Endosc
(2005) - et al.
Lower gastrointestinal bleeding
Gastrointest Endosc Clin N Am
(2007) - et al.
Gastrointestinal bleeding in the elderly
Gastrointest Endosc Clin N Am
(2001) Lower GI bleeding
- et al.
Effectiveness of current technology in the diagnosis and management of lower gastrointestinal hemorrhage
Gastrointest Endosc
(1995) - et al.
Risk factors for mortality in lower intestinal bleeding
Clin Gastroenterol Hepatol
(2008) - et al.
An annotated algorithmic approach to acute lower gastrointestinal bleeding
Gastrointest Endosc
(2001) - et al.
American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding
Gastroenterology
(2007) - et al.
Diverticular disease of the colon, a 20th century problem
Clin Gastroenterol
(1975) Natural history of diverticular disease of the colon
Clin Gastroenterol
(1975)
Diverticular disease in the elderly
Gastrointest Endosc Clin N Am
The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding
Clin Gastroenterol Hepatol
Differential diagnosis of gastrointestinal bleeding
Techniques in vascular and interventional radiology
Serious lower gastrointestinal clinical events with nonselective NSAID or coxib use
Gastroenterology
Risk factors predictive of severe diverticular hemorrhage
Int J Surg
Endoscopic therapy of acute diverticular hemorrhage
Am J Gastroenterol
Colonoscopy with clipping is useful in the diagnosis and treatment of diverticular bleeding
Clin Gastroenterol Hepatol
Lower gastrointestinal bleeding
Gastrointest Endosc Clin N Am
Timing of colonoscopy: impact on length of hospital stay in patients with acute lower intestinal bleeding
Am J Gastroenterol
Early colonoscopy for acute lower GI bleeding predicts shorter hospital stay: a retrospective study of experience in a single center
Gastrointest Endosc
Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes
Gastrointest Endosc
Cardiac sources of embolism should be routinely screened in ischemic colitis
Am J Gastroenterol
Ischemic bowel disease in the elderly
Gastrointest Endosc Clin N Am
The colon single-stripe sign and its relationship to ischemic colitis
Am J Gastroenterol
Ischemic colitis: spectrum of disease and outcome
Surgery
Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis
Am J Gastroenterol
Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge
Gastroenterology
Factors that contribute to blood loss in patients with colonic angiodysplasia from a population-based study
Clin Gastroenterol Hepatol
On the nature and etiology of vascular ectasias of the colon: degenerative lesions of aging
Gastroenterology
Lower gastrointestinal bleeding—management
Gastrointest Endosc Clin N Am
Lower GI bleeding: epidemiology and diagnosis
Gastrointest Endosc Clin N Am
Ability of naloxone to enhance the colonoscopic appearance of normal colon vasculature and colon vascular ectasias
Gastrointest Endosc
The role of endoscopy in patients with anorectal disorders
Gastrointest Endosc
The role of colonoscopy in evaluating hematochezia: a population-based study in a large consortium of endoscopy practices
Gastrointest Endosc
Complications of colonoscopy
Gastrointest Endosc
Objective evidence of aspirin use in both ulcer and nonulcer upper and lower gastrointestinal bleeding
Gastroenterology
Selective cyclooxygenase-2 inhibitors and relapse of inflammatory bowel disease
Gastroenterology
Side effects of nonsteroidal anti-inflammatory drugs on the small and large intestine in humans
Gastroenterology
Major stigmata of recent hemorrhage on rectal ulcers in patients with severe hematochezia: endoscopic diagnosis, treatment, and outcomes
Gastrointest Endosc
Acute major gastrointestinal hemorrhage in inflammatory bowel disease
Gastrointest Endosc
Acute lower gastrointestinal bleeding in Crohn's disease: characteristics of a unique series of 34 patients. Belgian IBD Research Group
Am J Gastroenterol
Etiology and outcome of lower gastrointestinal bleeding in patients with AIDS
Am J Gastroenterol
Evaluation and treatment of gastrointestinal tract hemorrhage in patients with AIDS
Gastrointest Endosc Clin N Am
The role of endoscopy in the management of acute non-variceal upper GI bleeding
Gastrointest Endosc
Management of antithrombotic agents for endoscopic procedures
Gastrointest Endosc
Early predictors of severe lower gastrointestinal bleeding and adverse outcomes: a prospective study
Clin Gastroenterol Hepatol
The role of endoscopy in the patient with lower gastrointestinal bleeding
Gastrointest Endosc
GRADE: an emerging consensus on rating quality of evidence and strength of recommendations
BMJ
Acute lower GI bleeding
Acute gastrointestinal bleeding. Experience of a specialized management team
J Clin Gastroenterol
Cited by (149)
Gastrointestinal Bleeding in Patients Supported with Left Ventricular Assist Devices: The Journey from Bridging to Destination
2023, American Journal of CardiologyColorectal Oncologic Emergencies: Recognition, Management, and Outcomes
2023, Surgical Clinics of North AmericaTiming of colonoscopy in acute lower GI bleeding: a multicenter retrospective cohort study
2023, Gastrointestinal EndoscopyColorectal Cancer in Younger Adults
2022, Hematology/Oncology Clinics of North AmericaA Multicenter Randomized Controlled Trial Comparing Two Bowel Cleansing Regimens for Colonoscopy After Failed Bowel Preparation
2022, Clinical Gastroenterology and Hepatology
This document is a product of the ASGE Standards of Practice Committee. This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.