Lower Gastrointestinal Bleeding

The spontaneous remission rates for lower gastrointestinal bleeding is 80 percent. No source of bleeding can be identified in 12 percent of patients, and bleeding is recurrent in 25 percent. Bleeding has usually ceased by the time the patient presents to the emergency room.

I. Clinical evaluation

A. The severity of blood loss and hemodynamic status should be assessed immediately. Initial management consists of resuscitation with crystalloid solutions (lactated Ringers solution) and blood products if necessary.

B. The duration and quantity of bleeding should be assessed; however, the duration of bleeding is often underestimated.

C. Risk factors that may have contributed to the bleeding include and nonsteroidal anti-inflammatory drugs, anticoagulants, colonic diverticulitis, renal failure, coagulopathy, colonic polyps, and hemorrhoids. Patients may have a prior history of hemorrhoids, diverticulosis, inflammatory bowel disease, peptic ulcer, gastritis, cirrhosis, or esophageal varices.

D. Hematochezia. Bright red or maroon output per rectum suggests a lower GI source; however 12 to 20% of patients with an upper GI bleed may have hematochezia as a result of rapid blood loss.

E. Melena. Sticky, black, foul-smelling stools suggest a source proximal to the ligament of Treitz, but Melena can also result from bleeding in the small intestine or proximal colon.

F. Change in stool caliber, anorexia, weight loss and malaise are suggestive of malignancy.

G. Clinical findings

1. Abdominal pain may result from ischemic bowel, inflammatory bowel disease, or a ruptured aneurysm.

2. Painless massive bleeding suggests vascular bleeding from diverticula, angiodysplasia, or hemorrhoids.

3. Bloody diarrhea suggests inflammatory bowel disease or an infectious origin.

4. Bleeding with rectal pain is seen with anal fissures, hemorrhoids, and rectal ulcers.

5. Chronic constipation suggests hemorrhoidal bleeding. New onset of constipation or thin stools suggests a left sided colonic malignancy.

6. Blood on the toilet paper or dripping into the toilet water suggests a perianal source of bleeding, such as hemorrhoids or an anal fissure.

7. Blood coating the outside of stools suggests a lesion in the anal canal.

8. Blood streaking or mixed in with the stool may results from polyps or a malignancy in the descending colon.

9. Maroon colored stools often indicate small bowel and proximal colon bleeding.

II. Physical examination A. Postural hypotension indicates a 20% blood volume loss, whereas, overt signs of shock (pallor, hypotension, tachycardia) indicates a 30 to 40 percent blood loss.

B. The skin may be cool and pale with delayed refill if bleeding has been significant.

C. Stigmata of liver disease, including jaundice, caput medusae, gynecomastia and palmar erythema, should be sought because patients with these findings frequently have GI bleeding.

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