Guideline
The role of endoscopy in the patient with lower GI bleeding

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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.

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    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.

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