Approach to Lower

GI Bleeding
Dr. Noble Varghese Mathews
Resident , Institute of MGE
Madras medical college
Topics Covered
• Overview
• Etiology
• Clinical manifestations
• Diagnostic Modalities
• Evaluation and Management
Overview
• Definition – Bleeding originating from a site distal to ligament
of treitz.
• The annual incidence of LGI bleeding is approximately
20/1,00,000, with an increased risk in older adults.
• Rate of hospitalisation is lower than UGI bleed.
• Most have painless hematochezia +/- decrease in hematocrit.
Sites of origin of severe hematochezia (UCLA CURE)
Etiology of LGI bleed
• There are differences between western countries and
developing countries with regards to different etiologies of
LGIB.
• This difference could be attributed to genetic, environmental,
dietary difference between the various ethnic groups.

Dar IA, Dar WR, Khan MA, Kasana BA, Sofi NU, Hussain M, Arshad F, Wani MA, Latief M, Sodhi JS.
Etiology, clinical presentation, diagnosis and management of lower gastrointestinal bleed in a Tertiary Care Hospital in India:
A retro-prospective study. J Dig Endosc 2015;6:101-9
Causes of LGI bleed
Diagnosis Frequency (%)
Diverticulosis 30
Colitis 21

Hemorrhoids 14
Ischemic 12
IBD 9
Post-polypectomy 8
Colon cancer/polyps 6
Rectal ulcer 6
Vascular ectasia 3
Radiation colitis/proctitis 3
Other 6

UCLA CURE (University of California,Los angeles Centre for ulcer research and education) database
Causes of LGI bleed
Diagnosis Frequency (%)
Polyps 23.3
Others(LNH, non-specific ulcers, infective 21
and ischemic colitis)
IBD 17.7
Malignancy 12
Angiodysplasia 9
Diverticulosis 8
Hemorrhoids 5.3
Undiagnosed 3.7

Dar IA, Dar WR, Khan MA, Kasana BA, Sofi NU, Hussain M, Arshad F, Wani MA, Latief M, Sodhi JS.
Etiology, clinical presentation, diagnosis and management of lower gastrointestinal bleed in a Tertiary Care Hospital in India:
A retro-prospective study. J Dig Endosc 2015;6:101-9
Other data from developing countries
• Wajeehudin et al. studied 80 patients and found that polyps
were the most common cause of LGIB constituting (56%).
• Mozhgan Zahmatkeshan et al. did a study in 363 patients of
LGIB and found 25% causes of LGIB due to polyps and 10.2%
due to IBD.
• Farzaneh Motamed et al. in their study found that 34.7% cases
of LGIB were due to polyps.
• Bai and Jun Penget found the prevalence of IBD as a cause of
LGIB in 20% patients.
CLINICAL MANIFESTATIONS
• LGI bleeding typically reports hematochezia (passage of
maroon or bright red blood or blood clots per rectum).
• Blood originating from the left colon tends to be bright red in
color, whereas bleeding from the right side of the colon
usually appears dark or maroon colored and may be mixed
with stool.
• Rarely, bleeding from the right side of the colon /small
intestine will present with melena.
History and physical exam
• Patients should be asked about prior episodes of GI bleeding.
• Past medical history should be reviewed to identify potential
bleeding sources and to identify comorbidities(Hypertension, CLD)
that may influence the patient's subsequent management.
• Medication use - particularly agents that are associated with
bleeding or that may impair coagulation, such as NSAIDs,
anticoagulants, and antiplatelet agents.
• Symptoms that may suggest a particular etiology for the bleeding
(Eg- painless hematochezia - diverticular bleeding/malignancy,
change in bowel habits with malignancy, abdominal pain suggests
an inflammatory bleeding source - ischemic or infectious colitis or
a perforation, Pain on defecation – fissures/hemorrhoids)
• Alcohol abuse in case of suspected cirrhosis.
Physical examination

• Hemodynamic instability
• Mild to moderate hypovolemia: Resting tachycardia
• Blood volume loss of at least 15 percent: Orthostatic
hypotension.
• Blood volume loss of at least 40 percent: Supine hypotension
Clinical factors predicting severe LGI
bleed
• Continued bleeding within first 24 hours of
admission/transfusion requirement of at least 2 units of
PRBCs/decrease in hematocrit of 20% or more)
• Recurrent bleeding after 24 hrs of admission/need for
additional transfusions.
• Readmission for LGI bleed within one week of discharge for
the same.
• Tachycardia/hypotension/syncope/non tender
abdomen/rectal bleeding on presentation/aspirin use/2 or
more comorbid illnesses.
Clinical prediction score and outcome of
severe acute LGI bleeding
Total risk Frequency Risk of Need for Mortality Hospital Mean
points (%) Severe surgery rate(%) days(%) number of
bleeding( (%) PRBCs
%) transfused
0 6 6 0 0 2.8 0
1-3 75 43 1.5 2.9 3.1 1
≥4 19 79 7.7 9.6 4.6 3

One point each – aspirin use, >2 comorbid illness, HR>100/min, non-tender abdomen,
SBP<115 mmhg, rectal bleed within 4 hours of admission, syncope.

Strate, L., Saltzman, J., Ookubo, R. et al, Validation of a clinical prediction rule for severe acute lower intestinal bleeding. Am J Gastroenterol. 2005;100:1821–1827
?UGI source
• Consider an upper GI bleeding source — The primary
consideration in the differential diagnosis of hematochezia is
upper GI bleeding since 10 to 15 percent of patients with
severe hematochezia will have an upper GI source.
• Findings that are suggestive of an upper GI source include -
hemodynamic instability, orthostatic hypotension, and an
elevated BUN-to-creatinine >20 to 30:1.
• Blood clots in the stool decrease the likelihood of an upper GI
source.

Farrell JJ, Friedman LS. Review article: the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther 2005; 21:1281.
Evaluation and management
• Resuscitation and initial assessment
• Localization of the bleeding site
• Therapeutic intervention to stop bleeding at the site
Resuscitation and initial assessment
• The timing and setting of the evaluation depends upon the
severity of bleeding and the patient's comorbid illnesses.
• Patients with high-risk features - hemodynamic instability,
persistent bleeding, and/or significant comorbid illnesses
should be admitted to an ICU for resuscitation, close
observation, and possible therapeutic interventions.
• Close observation includes automated blood pressure
monitoring, electrocardiogram monitoring, and pulse
oximetry.
• Most other patients can be admitted to a regular medical
ward. All patients admitted to a regular medical ward receive
electrocardiogram monitoring.
Resuscitation and initial assessment
• A large study in 143 hospitals in the UK, identified patients
with acute lower GI bleeding who could be safely managed
without hospital admission.
• Age, prior history of lower GI bleeding, presence of blood on
rectal exam, heart rate, systolic blood pressure and
hemoglobin concentration were the features used to
determine safe discharge.
• A score of ≤8 predicted a 95 percent probability of safe
discharge
• This score was better than the Rockall, Blatchford, Strate,
BLEED, AIMS65, and NOBLADS scores in predicting safe
discharge.
Oakland K, Jairath V, Uberoi R, et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study.
Lancet Gastroenterol Hepatol 2017; 2:635.
Resuscitation and initial assessment
• Blood products in patients with acute lower GI bleeding should
be individualized. (GENERALLY NOT REQUIRED)
• Patients with active bleeding and a coagulopathy (prolonged
prothrombin time with international normalized ratio greater
than 1.5) or low platelet count (less than 50,000/microL) should
be transfused with fresh frozen plasma (FFP) and platelets,
respectively.
• Platelet and plasma transfusions should also be considered in
patients who receive massive RBC transfusions (>3 units of
packed RBCs within one hour).
• In patients with an INR of 1.5-2.5, endoscopic hemostasis may
be performed before or concomitant with the administration of
reversal agents. However, in patients with an INR >2.5, reversal
agents should generally be administered before endoscopy.
ASGE Standards of Practice Committee, Acosta RD, Abraham NS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy.
Gastrointest Endosc 2016; 83:3.
Localization of the bleeding site
• Most patients should undergo initial evaluation with
colonoscopy after bowel preparation.
• In selected cases, an anoscopy or flexible sigmoidoscopy is
performed after an enema.
Diagnostic Modalities
• Anoscopy
• Flexible sigmoidoscopy
• Colonoscopy
• Radionuclide imaging
• Angiography
• CT colonography
• Barium enema
Diagnostic Modalities
• Anoscopy – useful in actively bleeding patients who are
supected to have anorectal disorders(fissures,fistulas,proctitis)
• Allows immediate treatment with rubber band ligation for
bleeding internal hemorrhoids.
Diagnostic Modalities
• Flexible sigmoidoscopy – Evalaute the rectum and left colon
without any standard bowel preparation.
• Useful in suspected cases of solitary rectal ulcer, UC, radiation
proctitis, ischemic colitis, post polypectomy bleed, internal
hemorrhoids.
• Therapeutic hemostasis can be provided with injection
therapy, hemoclip placement, band ligation or MPEC
• Monopolar electrocautery(APC,snare polypectomy,hot biopsy
forceps) should not be used without bowel preparation.
Diagnostic Modalities
• Colonoscopy – Bowel preparation is required.
• Metoclopramide 10mg IV may be given every 4 hours to
facilitate gastric emptying and reduce nausea.
• Urgent colonscopy is done 6-36 hours after patient is
admitted.
• Most bleeding stops spontaneously- so done semi-electively.
Diagnostic Modalities
• The overall rate of detecting a presumed LGI bleed by
colonoscopy ranges from 48%-90%, with an average of 68%.
• The optimal time for performing urgent bowel preparation
and colonoscopy is unknown.
• In diverticular bleeding, the timing of endoscopy is not
significantly associated with the finding of active bleeding or
other stigmata that would prompt colonoscopic hemostasis.
(Mayo clinic)
• A prospective study revealed no difference between
urgent(<12hrs) and elective(36-60 hrs) colonoscopy in terms
of further bleeding, blood transfusions, hospital days, or
hospital charges*
• Early colonoscopy has been associated with a shorter length of
hospitalization, principally because of improved diagnostic
yield rather than therapeutic intervention**

* Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol 2010; 105:2636-41
** Strate LL, Syngal S. Timing of colonoscopy: Impact on length of hospital stay in patients with acute lower intestinal bleeding. Am J Gastroenterol 2003; 98:317-22
Diagnostic Modalities
• Angiography - most likely to detect a site of bleeding when the
rate of arterial bleeding is at least 0.5 mL/min.
• Positive results in 12% to 69% of cases.
• Embolization can be performed to control some bleeding
lesions.
• Disadvantages of angiography - Major complications occur in
3% and include bowel ischemia, hematoma formation,
femoral artery thrombosis, contrast dye reactions, AKI, and
TIAs.
• Absence of active bleeding in most patients at the time of
angiography
• Inability to detect non-bleeding stigmata of hemorrhage
(NBVV, clot, or spot)
• Expense of the test
• Inability to determine the specific lesion responsible for
bleeding in many cases
Diagnostic Modalities
• CT and CT colonography
• CT is often performed if the patient is having hematochezia with
abdominal pain.
• CT can identify abnormalities in the colon that could be a source of
bleeding, such as diverticulosis, colitis, masses, and varices.
• CT colonography is being used increasingly to screen persons for
colonic polyps and cancer and may be of some benefit in patients
with LGI bleeding.
• CT colonography detects large polyps (>1 cm) or cancers with a
sensitivity rate of 90%
• Disadvantage- Exposes the patient to unnecessary radiation, and
because nearly all patients will undergo either urgent or elective
colonoscopy anyway.
Diagnostic Modalities
• Radionuclide imaging - involves injecting a radiolabeled
substance into the patient’s bloodstream and performing
serial scintigraphy to detect focal collections of radiolabeled
material.
• Detects bleeding at a rate as low as 0.04 mL/min.
• May be helpful in cases of obscure GI bleeding
• The disadvantages of radionuclide imaging are that delayed
scans may be misleading, and determining the specific cause
of bleeding often depends on endoscopy or surgery.
• False-positive results are most likely to occur when transit of
luminal blood is rapid, such that radiolabeled blood is
detected in the colon even though it originated in the UGI
tract.
Diagnostic Modalities
• Barium enema- Emergency barium enema has no role in
patients with LGI bleeding.
• This test is rarely diagnostic, because it cannot demonstrate
vascular lesions and may be misleading if only diverticula are
seen.
• It fails to detect 50% of polyps larger than 10 mm.
• Barium contrast liquid can make urgent colonoscopy more
difficult by impairing visualization.
• Subsequent colonoscopy is always needed for any suspicious
lesions seen on barium enema or for lesions that require
therapy.
Role of surgery
• Surgical management is rarely needed in patients with LGI
bleeding, because most bleeding is self-limited or easily
managed with medical or endoscopic therapy.
• The main indications for surgery are malignancy, diffuse
bleeding that fails to cease with medical therapy (as in
ischemic or UC), and recurrent bleeding from a diverticulum.
Diverticulosis
• Herniations of colonic mucosa and submucosa through the
muscular layers of the colon.
• Diverticula form when colonic tissue is pushed out by
intraluminal pressure at points of entry of the small arteries.
 Diverticulosis
• Most commonly in the left colon.
• Most remain asymptomatic
• Common in western countries.
• Bleeding may occur from vessels at the neck(52%)or
base(48%) of a diverticulum*
• Bleeding occurs in about 3% to 5% of patients with
diverticulosis-mostly painless.
• Diverticula in the right colon are more likely to bleed.**

*Jensen D. Management of patients with severe hematochezia—with all current evidence available. Am J Gastroenterol 2005; 100:2403-6
**Meyers MA, Alonso DR, Gray GF, et al. Pathogenesis of bleeding colonic diverticulosis. Gastroenterology 1976; 71:577-83
**McGuire HH Jr, Haynes BW Jr. Massive hemorrhage for diverticulosis of the colon: Guidelines for therapy based on bleeding patterns observed in fifty cases. Ann Surg 1972; 175:847-55.
**McGuire HH Jr. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg 1994; 220:653-6.
Diverticular Hemorrhage
• 3 Types
• Definitive Diverticular Hemorrhage(17%)
• Presumptive Diverticular Hemorrhage(31%)
• Incidental Diverticulosis(52%)
(In a large study by jensen in patients with severe hematochezia)*

*Jensen D. Management of patients with severe hematochezia—with all current evidence available. Am J Gastroenterol 2005; 100:2403-6.
 Diverticular Hemorrhage
• About one third of patients with true diverticular hemorrhage (presumptive or
definitive groups) during urgent colonoscopy have a stigma of recent bleeding,
such as active bleeding, visible vessel, a clot, or a flat spot in a single diverticulum.
• For an entire group of 37 patients with these high-risk stigmata, the rebleeding
rate on medical therapy was 65%, and the rate of intervention was 43%.
• UCLA CURE by using doppler probe has detected blood flow underneath 91% of
lesions with high risk stigmata and 0% in those without.
Endoscopic hemostasis
• If fresh red blood is seen in a focal segment of colon, that segment
should be irrigated vigorously with water to remove the blood and
identify the underlying bleeding site.
• If bleeding is coming from the edge of a diverticulum or a
pigmented protuberance is seen on the edge, a sclerotherapy
needle can be used for submucosal injection of epinephrine (diluted
1 : 20,000 in saline) in 1-mL aliquots into 4 quadrants around the
bleeding site. Subsequently, MPEC at a low power setting (10 to 15
W) and light pressure can be carried out for a 1-second pulse
duration to cauterize the diverticular edge and stop bleeding or
flatten the visible vessel, or hemoclips can be applied.
• A nonbleeding adherent clot can be injected with epinephrine, after
which the clot can be removed piecemeal by guillotining it with a
cold polyp snare until it extends 3 mm above the diverticulum. The
underlying stigma is treated with MPEC or hemoclips.
Endoscopic hemostasis
• Jensen and the UCLA CURE group published their results on
urgent colonoscopy for the diagnosis and treatment of severe
diverticular hemorrhage and reported that 20% of patients
with severe hematochezia had endoscopic stigmata,
suggesting a definitive diverticular bleed.
• This group of patients, who underwent colonoscopic
hemostasis, had a rebleeding rate of 0% and an emergency
hemicolectomy rate of 0%, compared with 53% and 35%,
respectively, in a historical control group of patients who had
high-risk stigmata but did not undergo colonoscopic
hemostasis

Jensen DM, Machicado GA, Jutabha R, et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000; 342:78-82.
Endoscopic hemostasis
• After endoscopic hemostasis of a bleeding diverticulum is
completed, a permanent submucosal tattoo should be placed
around the lesion to allow identification of the site in case
colonoscopy is repeated.
 Angiographic embolization and surgery
• Angiographic embolization can be performed in selected cases
of diverticular bleeding, but with a risk of bowel infarction,
contrast dye reactions, and acute kidney injury. One study
found that routine angiography prior to surgical resection is
not helpful in reducing the overall risk of complications.*
• Surgical resection for diverticular bleeding is rarely needed
and is reserved for recurrent bleeding.

Cohn SM, Moller BA, Zieg PM, et al. Angiography for preoperative evaluation in patients with lower gastrointestinal bleeding: Are the benefits worth the risks? Arch Surg 1998; 133:50-5.
Colitis
• Severe LGI bleeding may be caused by ischemic colitis,
inflammatory bowel disease, or possibly infectious colitis.
• Ischemic colitis can present as painless or painful
hematochezia with mild left-sided abdominal discomfort.
• The incidence of ischemic colitis is estimated to be 4.5 to 44
cases/100,000 person-years
Risk factors associated with ischemic
colitis
• Older age
• Shock
• Cardiovascular surgery,
• Heart failure
• COPD
• Ileostomy,
• Colon cancer
• Abdominal surgery
• Irritable bowel syndrome
• Constipation/laxative use
• OCP use
• H2 receptor antagonist
 Ischemic colitis
• The watershed area
between the superior and
inferior mesenteric arteries
has the fewest collateral
vessels and is at most risk
for ischemia(area near
splenic flexure).
Ischemic colitis
• Ischemic colitis generally resolves in a few days and generally
does not require colonoscopic hemostasis or antibiotic
therapy.
• In the UCLA CURE experience, approximately 10% of patients
with ischemic colitis and severe hematochezia had a focal
ulcer with a major stigma of hemorrhage on urgent
colonoscopy. The recommended treatment in these cases is
epinephrine injection and hemoclipping.
IBD
• Inflammatory bowel disease that involves the colon can rarely
cause severe acute LGI bleeding.
• In a case series from the Mayo Clinic, most of these patients
had Crohn’s disease, and most were successfully treated
medically.
• Infectious colitis should be excluded in any patient with severe
LGI bleeding and colitis.
• LGIbleeding can occur with infection caused by Campylobacter
jejuni, Salmonella, Shigella, enterohemorrhagic Escherichia
coli (O157:H7), cytomegalovirus, or Clostridium difficile.
• Treatment is medically with antibiotics
• Endoscopic management generally has no role in infectious
colitis.
 Post polypectomy bleed
• Bleeding occurs after
approximately 1% of
colonoscopic polypectomies.
• It is most common 5 to 7 days
after polypectomy
• Can occur from 1 to 14 days
after the procedure
• Generally self-limited and mild
to moderate, with 50% to 75%
of patients requiring blood
transfusions.
Risk factors
• Large polyp size (>2 cm)
• Thick stalk
• Sessile type
• Location in the right colon
• Concurrent medications- warfarin, heparin, aspirin or another
NSAID.
Management
• Endoscopic management techniques for delayed
postpolypectomy bleeding depend on the stigma found and
are similar to those used for peptic ulcer hemorrhage
including
• Epinephrine injection
• Thermal coagulation
• Hemoclip placement
• Combination therapy
Colon Polyps and Cancer
• Mostly patients have a microcytic iron deficiency anemia
consistent with slow GI blood loss.
• Can present with acute hematochezia.
• Epinephrine can be injected into the lesion to slow active
bleeding, and hemoclips can be applied to treat stigmata of
hemorrhage on ulcerated lesions that cannot be resected
endoscopically.
• Colon polyps can be removed to stop bleeding.
• Surgery to prevent rebleeding from a large ulcerated sessile
lesion.
Radiation proctitis
• Causes mild chronic hematochezia, occasionally can cause
acute severe LGI bleeding.
• Ionizing radiation can cause acute and chronic damage to the
normal colon and rectum when used to treat gynecologic,
prostatic, bladder, or rectal tumors.
• Acute self-limited diarrhea, tenesmus, abdominal cramping,
and rarely bleeding develops for a few weeks in approximately
75% of patients who have received a radiation dose of 4000
cGy.
Radiation proctitis
• Chronic radiation effects occur 6 to 18 months after
completion of treatment and manifest as bright red blood with
bowel movements.
• Bowel injury resulting from chronic radiation is related to
vascular damage » mucosal ischemia » thickening » ulceration.
• Much of this damage results from chronic hypoxic ischemia
and oxidative stress.
• Flexible sigmoidoscopy or colonoscopy reveals telangiectasias,
friability, and sometimes ulceration in the rectum.
• Active bleeding is common, and often other nonbleeding
rectal telangiectasias are seen.
Treatment-Radiation proctitis
• Avoidance of aspirin and other NSAIDs
• High-fiber diet, and iron supplementation.
• Topical or oral 5-aminosalicylic acid (mesalamine), sucralfate,
or glucocorticoids may be prescribed but are not generally
effective.
• Thermal therapy is usually successful, but repeated treatments
with MPEC or argon plasma coagulation are necessary to
achieve good outcomes.
• Topical formalin applied directly to the rectal mucosa can
reduce bleeding, as can the use of hyperbaric oxygen.
• Antioxidant vitamins, such as vitamins E and C, also have been
reported to decrease bleeding from chronic radiation proctitis.
Internal Hemorrhoids
• Hemorrhoidal bleeding is characterized by bright red blood
per rectum that can coat the outside of the stool, drip into the
toilet bowl.
• Often appear as a large amount of fresh blood in the toilet
• Bleeding is mild, intermittent, and self-limited
• Diagnosis can be made with anoscopy, sigmoidoscopy, or
colonoscopy, especially if performed while bleeding is ongoing
Treatment
• Medical therapy -Fiber supplementation, stool softeners,
lubricant rectal suppositories (with or without glucocorticoids)
and warm sitz baths.
• Anoscopic therapy -Injection sclerotherapy, rubber band
ligation, cryosurgery, infrared photocoagulation, MPEC, and
direct current electrocoagulation.
Rectal Varices
• Ectopic varices may develop in the rectal mucosa between the
superior hemorrhoidal veins (portal circulation) and middle
and inferior hemorrhoidal veins (systemic circulation) in
patients with portal hypertension.
• On sigmoidoscopy, rectal varices are seen during retroflexion
as vascular structures located several centimeters above the
dentate line and extending into the rectum.
• Increases with the degree of portal hypertension.
• About 60% of patients with a history of bleeding esophageal
varices have rectal varices.
• The treatment of bleeding rectal varices is with sclerotherapy,
band ligation, or a portosystemic shunt.
Anal fissure
• Present with painful bowel movements but can present with
hematochezia.
• Hematochezia is mild and is rarely moderate to severe.
• Treatment - healing the anal fissure, rather than using specific
hemostasis techniques.
• Topical calcium channel blocker (e.g., 2%topical diltiazem
cream) along with fiber supplementation, stool softeners, and
sitz baths will heal most anal fissures.
Rectal ulcers
• Solitary or multiple rectal ulcers located 3 to 10 cm above the
dentate line.
• Can present with severe hematochezia.
• Usually occurs in a critically ill patient , mostly elderly
• Etiology is proposed to be secondary to mucosal ischemia.
• Treatment is with combinations of thermal coagulation,
injection therapy, and suture ligation.
Obscure overt GI bleeding
• Obscure GI bleeding is commonly defined as GI bleeding of
uncertain cause after a nondiagnostic upper endoscopy,
colonoscopy, and barium small bowel follow-through.
• The cause of bleeding is not found on upper endoscopy and
colonoscopy in 5% of hospitalized patients with overt GI
bleeding.
• In 75% of these patients a bleeding site is located in the small
intestine.
Following possibilities
• The lesion was within reach of a standard endoscope and
colonoscope but not recognized as the bleeding site (e.g.,
Cameron’s lesions, angioectasias, internal hemorrhoids);
• The lesion was difficult to visualize (e.g., a blood clot obscured
visualization of the lesion; varices became inapparent in a
hypovolemic patient; a lesion was hidden behind a mucosal
fold) or present intermittently (e.g., Dieulafoy’s lesion,
angioectasias)
• The lesion is in the small intestine beyond the reach of
standard endoscopes (e.g., neoplasm, angioectasias,
diverticulum)
• Once it is certain that a bleeding lesion in the UGI or LGI tract
was not missed, the evaluation should focus on the small
intestine.
• Small bowel bleeding is often intermittent - radionuclide
imaging or angiography has limited value in the diagnostic
evaluation.
• Wireless video capsule endoscopy, deep enteroscopy, and CT
enterography - allow greater visualization and more
therapeutic options.
Causes of 0bscure GI bleed
• Angioectasia, also referred to as angiodysplasia, is the
formation of aberrant blood vessels found throughout the GI
tract that develop with advancing age.
• Arteriovenous malformations (AVMs), which are congenital,
and angiomas, which are neoplastic.
• Telangiectasia is the lesion that results from dilatation of the
terminal aspect of a blood vessel.
• Angioectasia occur in association with various disorders, such
as chronic kidney disease, cirrhosis, rheumatoid disorders,
Aortic stenosis, VWD, LVAD.
• Angioectasia may present as overt or occult bleeding. Most
commonly in colon and small intestine.
Angioectasia-pathogenesis
• Their formation in the colon is that partial, intermittent, low-
grade obstruction of submucosal veins during muscular
contraction and distention of the cecum results in dilatation
and tortuosity of the submucosal veins.
• Over time, the increased pressure also results in dilatation of
the venules, capillaries, and arteries of the mucosal
vasculature.
• Finally, precapillary sphincters can become incompetent,
thereby causing arteriovenous communications to develop
and result in local mucosal ischemia.
TREATMENT

• Endoscopic treatment - injection therapy with epinephrine,

thermal probe coagulation, argon plasma coagulation and
band ligation.
• Estrogen – routine use not recommended.
• Thalidomide – angiogenesis inhibitor
Telangiectasias
• Seen in HHT {diffuse telangiectasias and large AVMs.
• Telangiectasias on lips and buccal mucosa. Cerebral and pulmonary
AVMs.
• The diagnosis of HHT is based on 4 criteria: (1) spontaneous and
recurrent epistaxis, (2) multiple mucocutaneous telangiectasias, (3)
visceral AVMs (4) a first-degree relative with HHT.
• Genetic testing to detect mutations in the ENG, ALK-1, or MAHD4
TREATMENT
• Endoscopic Hemostasis
• Hormonal therapy
• Embolisation of large AVMs
Meckels Diverticulum
• Congenital blind intestinal pouch that results from incomplete obliteration of the
vitelline duct
• “rule of 2s”:
• They occur in 2% of the population, found within 2 feet of the ileocecal valve, 2
inches long, result in a complication in 2% of cases, have 2 types of ectopic tissue
(gastric and pancreatic) within the diverticulum, present clinically most commonly
at age 2 (with intestinal obstruction), and have a male-to-female ratio of more than
2 : 1.
• HPE - ectopic gastric mucosa, which can lead to acid secretion and ulceration in up
to 75% of patients.
• The diagnostic test for a Meckel’s diverticulum is a 99mTc-pertechnetate scan- high
specificity (almost 100%) and positive predictive value but can be negative in the
25% to 50% of patients in whom the diverticulum does not contain ectopic gastric
mucosa.
• The accuracy of the Meckel’s scan can be improved with administration of an H2
receptor antagonist for 24 to 48 hours before the test.
• Others - capsule endoscopy and double-balloon enteroscopy
Other causes of small intestinal bleed
• NSAID induced ulcers and erosions
• Small intestinal neoplasms
• Small intestinal diverticula
• Dieulafoy’s lesion
• Blue rubber bleb Nevus syndrome
Endoscopic hemostasis
• Push enteroscopy
• Intra operative Endoscopy
• Capsule endoscopy
Push enteroscopy
• Performed with a colonoscope (160 to 180 cm in length) or dedicated
push enteroscope (220 to 250 cm in length).
• These endoscopes can be used to evaluate the esophagus, stomach,
duodenum, and proximal jejunum approximately 50 to 150 cm beyond
the ligament of Treitz.
• Insertion is often limited by looping of the endoscope in the stomach.
• Push enteroscopy identifies a potential bleeding site in about 50% of
patients, and roughly 50% of lesions found are within reach of a
standard upper endoscope
• The overall diagnostic yield of push enteroscopy is approximately 40%,
with a range of 3% to 80%.
• Most commonly detected lesions are angioectasias.
• In the UCLA CURE hemostasis experience in patients with recurrent
severe, obscure, overt GI bleeding manifesting as melena, the
diagnostic yield has been 80%
Deep enteroscopy of jejunum and ileum
• Ultraflexible, 200-cm-long enteroscopes are used in
conjunction with an overtube to advance the endoscope by
pleating the small intestine over it.
• Double-balloon endoscope (with a balloon on the tip of the
endoscope and another balloon on the overtube),
• Single-balloon system (a balloon on the overtube only)
• Spiral overtube (no balloon used).
• All enteroscopes work by pleating the small intestine over the
endoscope.
• Can be inserted orally (antegrade) and advanced into the
proximal to midileum or inserted rectally (retrograde) and
advanced to the distal to midileum.
Intra operative Endoscopy
• Small bowel should be palpated (“running the bowel”) to
detect mass lesions.
• Exploratory laparotomy or laparoscopy is performed first to
lyse any adhesions and look for obvious tumors, a Meckel’s
diverticulum, or large vascular lesions.
• The small bowel is usually extracted through the abdominal
incision to allow the surgeon to assist with advancement of an
endoscope within the lumen of the GI tract, which allows
mucosal visualization as well as transillumination.
• Various endoscopes can be used (panendoscope, pediatric
colonoscope, or push enteroscope), depending on the route of
access.
 Capsule Endoscopy
• With capsule endoscopy, the patient ingests a pill camera that
transmits images of the small intestine over the course of
approximately 8 hours.
• In patients with severe recurrent GI bleeding, this technique can
identify a transition point at which fresh blood appears in the small
bowel, and thereby detect a potential bleeding site.
• Does not permit the application of therapy and can only localize a
lesion in the small bowel on the basis of the time of passage down
the small intestine, as determined by sensors on the abdomen and
telemetry.
• Provides useful information in directing subsequent therapeutic
procedures such as deep enteroscopy, angiography, or surgery.
ACG Clinical Guideline: Management of Patients with
Acute Lower Gastrointestinal Bleeding
• Evaluation and risk stratification
• A focused history, physical examination, and
laboratory evaluation should be obtained at the time of
patient presentation.
• Hematochezia associated with hemodynamic
instability may be indicative of an UGIB source, and an upper
endoscopy should be performed. A nasogastric
aspirate/lavage may be used to assess a possible upper GI
source if suspicion of UGIB is moderate.
• Risk assessment and stratification should be
performed to help distinguish patients at high and low risks of
adverse outcomes and assist in patient triage including the
timing of colonoscopy and the level of care.
ACG Clinical Guideline: Management of Patients with
Acute Lower Gastrointestinal Bleeding
• Hemodynamic resuscitation
• Patients with hemodynamic instability and/or
suspected ongoing bleeding should receive intravenous fluid
resuscitation with the goal of normalization of blood pressure
and heart rate prior to endoscopic evaluation/intervention.

• Packed red blood cells should be transfused to

maintain the hemoglobin above 7 g/dl. A threshold of 9 g/dl
should be considered in patients with massive bleeding,
significant comorbid illness (especially cardiovascular
ischemia), or a possible delay in receiving therapeutic
interventions.
ACG Clinical Guideline: Management of Patients with
Acute Lower Gastrointestinal Bleeding
• Management of anticoagulant medications
• Endoscopic hemostasis may be considered in patients with an INR
of 1.5–2.5 before or concomitant with the administration of reversal
agents. Reversal agents should be considered before endoscopy in
patients with an INR >2.5.
• Platelet transfusion should be considered to maintain a platelet
count of 50×10/l in patients with severe bleeding and those requiring
endoscopic hemostasis .
• Platelet and plasma transfusions should be considered in patients
who receive massive red blood cell transfusions.
• In patients on anticoagulant agents, a multidisciplinary approach
(e.g., hematology, cardiology, neurology, and gastroenterology) should be
used when deciding whether to discontinue medications or use reversal
agents to balance the risk of ongoing bleeding with the risk of
thromboembolic events (strong recommendation, very-low-quality
evidence
ACG Clinical Guideline: Management of Patients with
Acute Lower Gastrointestinal Bleeding
• Colonoscopy as a diagnostic tool
• Colonoscopy should be the initial diagnostic
procedure for nearly all patients presenting with acute LGIB
• The colonic mucosa should be carefully inspected
during both colonoscope insertion and withdrawal, with
aggressive attempts made to wash residual stool and blood in
order to identify the bleeding site. The endoscopist should
also intubate the terminal ileum to rule out proximal blood
suggestive of a small bowel lesion
ACG Clinical Guideline: Management of Patients with
Acute Lower Gastrointestinal Bleeding
• Timing of colonoscopy
• In patients with high-risk clinical features and signs or
symptoms of ongoing bleeding, a rapid bowel purge should be
initiated following hemodynamic resuscitation and a
colonoscopy performed within 24 h of patient presentation
after adequate colon preparation to potentially improve
diagnostic and therapeutic yield.
• In patients without high-risk clinical features or
serious comorbid disease or those with high-risk clinical
features without signs or symptoms of ongoing bleeding,
colonoscopy should be performed next available after a colon
purge.
ACG Clinical Guideline: Management of Patients with
Acute Lower Gastrointestinal Bleeding
• Endoscopic hemostasis therapy
• Endoscopic therapy should be provided to patients with high-risk
endoscopic stigmata of bleeding: active bleeding (spurting and oozing); non-
bleeding visible vessel; or adherent clot.
• Diverticular bleeding: through-the-scope endoscopic clips are
recommended, as clips may be safer in the colon than contact thermal therapy and
are generally easier to perform than band ligation, particularly for right-sided colon
lesions
• Angioectasia bleeding: noncontact thermal therapy using argon plasma
coagulation is recommended
• Post-polypectomy bleeding: mechanical (clip) or contact thermal
endotherapy, with or without the combined use of dilute epinephrine injection, is
recommended.
• Epinephrine injection therapy (1:10,000 or 1:20,000 dilution with saline) can
be used to gain initial control of an active bleeding lesion and improve visualization
but should be used in combination with a second hemostasis modality including
mechanical or contact thermal therapy to achieve definitive hemostasis
•
ACG Clinical Guideline: Management of Patients with
Acute Lower Gastrointestinal Bleeding
• A surgical consultation should be requested in patients with
high-risk clinical features and ongoing bleeding. It is important to
very carefully localize the source of bleeding whenever possible
before surgical resection to avoid continued or recurrent bleeding
from an unresected culprit lesion.
• Radiographic interventions should be considered in
patients with high-risk clinical features and ongoing bleeding who
have a negative upper endoscopy and do not respond adequately
to hemodynamic resuscitation efforts and are therefore unlikely
to tolerate bowel preparation and urgent colonoscopy
• If a diagnostic test is desired for localization of the bleeding
site before angiography, CT angiography should be considered
ACG Clinical Guideline: Management of Patients with
Acute Lower Gastrointestinal Bleeding

• Prevention of recurrent lower gastrointestinal bleeding

• Non-aspirin NSAID use should be avoided in patients with a
history of acute LGIB, particularly if secondary to diverticulosis or
angioectasia
• In patients with established high-risk cardiovascular disease
and a history of LGIB, aspirin used for secondary prevention should not
be discontinued. Aspirin for primary prevention of cardiovascular
events should be avoided in most patients with LGIB.
• In patients on DAPT or monotherapy with non-aspirin
antiplatelet agents, non-aspirin antiplatelet therapy should be resumed
as soon as possible and at least within 7 days. (as above, aspirin use
should not be discontinued). However, dual antiplatelet therapy should
not be discontinued in patients with an acute coronary syndrome
within the past 90 days or coronary stenting within 30 days.