Lower Gastrointestinal Bleeding: Diagnosis and Management

Abstract

Lower gastrointestinal (GI) hemorrhage refers to bleeding that originates distal to the Treitz ligament. Although more than 80 % of these hemorrhages spontaneously resolve or respond to medical and/or endoscopic treatment, acute and massive hemorrhage may represent a life-threatening condition with a 5–10 % mortality. The colon is the first site of bleeding, and common causes include diverticula and angiodysplasia. In the case of occult or self-limited hemorrhage, the potential source is identified using endoscopy of a well-prepared bowel. For acute and massive lower GI bleeding, because colonoscopy may be hampered by the absence of preparation or poor visualization of the intestinal wall, multidetector computed tomography angiography (MDCTa) has progressively emerged as a highly efficient and useful triaging tool. MDCTa could become the investigation used first to identify the location and cause of lower GI bleeding and orient patients according to the different available therapeutic options, including endoscopy, transcatheter embolization, and surgery. Superselective embolization is highly successful and safe, with high technical and clinical success rates. Surgery is a last-resort option for uncontrolled bleeding. It requires a thorough examination of the bowel, including intraoperative enteroscopy with transillumination when the location of the bleed is unknown, which represents the worst situation. The use of segmental versus subtotal colectomy, both of which are associated with significant mortality, is debated depending on the certainty of the location and cause of the bleeding.