Lower gastrointestinal bleeding
Encyclopedia
Lower gastrointestinal bleeding, commonly abbreviated LGIB, refers to any form of bleeding in the lower gastrointestinal tract. LGIB is a common ailment seen at emergency departments. It presents less commonly than upper gastrointestinal bleeding
(UGIB). It is estimated that UGIB accounts for 100-200 per 100,000 cases versus 20-27 per 100,000 cases for LGIB. Approximately 85% of lower gastrointestinal bleeding involves the colon, 10% are from bleeds that are actually upper gastrointestinal bleeds, and 3 - 5% involve the small intestines. The mortality rate for LGIB is between 2-4%.
. This includes the last 1/4 of the duodenum
and the entire area of the jejunum
, ileum
, colon
, rectum
, and anus.
The stool
of a person with a lower gastrointestinal bleed is a good (but not infallible) indication of where the bleeding is occurring. Black tarry appearing stools medically referred to as Melena
usually indicates blood that has been in the GI tract for at least 8 hours. Melena is four-times more likely to come from an upper gastrointestinal bleed than from the lower GI tract; however, it can also occur in either the duodenum and jejunum, and occasionally the portions of the small intestine
and proximal colon. Bright red stool, called hematochezia
, is the sign of a fast moving active GI bleed. The bright red or Maroon color is due to the short time taken from the site of the bleed and the exiting at the anus. The presence of hematochezia is six-times greater in a LGIB than with a UGIB.
Occasionally, a person with a LGIB will not present with any signs of internal bleeding. In these cases, a diagnostic assessment or pre-assessment should watch for other signs and symptoms that the patient may present with. These include, but are not limited to, hypotension
, tachycardia
, angina
, syncope
, weakness
, confusion
, stroke
, myocardial infarction
/heart attack, and shock.
The following are possible diagnosis of a LGIB:
Evaluations will most often be conducted by either a clinic triage
nurse, emergency department nurse, and/or a physician or other clinican. The initial assessment will include the appearance of the individual, their vital signs, and mental status. A patient history will help reveal a disposition or history of LGIBs or potential differential diagnosis.
Orthostatic vital signs
are often used as an indicator of hypovolemia.
Laboratory test will also help give indications of a LGIB. Hemoglobin
, hematocrit
, and platelets are very good physical signs of hypovolemia or blood loss anemia. Partial thromboplastin time
(PTT) and INR
will also help determine the body's current ability to clot.
Aspiration
of the stomach contents by way of a nasogastric tube (NG tube) will help differentiate between either a UGIB and a LGIB. A negative presence of blood will help to rule out an UGIB.
, physicians or other clinicians begin to rule out what the illness is not to narrow the diagnosis of the specific disease process, as with a lower gastrointestinal bleed.
Diverticulosis, Angiodysplasia, Infectious Colitis, Ischemic Colitis, Inflammatory Bowel Disease, Neoplasms, Radiation Telangiectasia and Proctitis, and NSAID Enteropathy and Colopathy are the causes of LGIB in adults.
The most common cause of massive bleeding in pediatric patients is Meckels Diverticulum. Anorectral disease (hemorrhoids and fissures) causes less severe bleeding in pediatric patients.
If a patient is suspected of having severe blood loss
they will most likely be placed on a vital sign monitor and administered oxygen either by nasal cannula
or simple face mask
. An intravenous catheter
will be placed into an easily accessible area and IV fluids will be administered to replace lost volume.
Surgical intervention
is warranted in some cases. It is most likely that a surgical consult
will be ordered if the patient is unable to be stabilized by non-invasive techniques, or a perforation is found that requires surgery.
Upper gastrointestinal bleeding
Upper gastrointestinal bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon.Upper GI bleeds are considered...
(UGIB). It is estimated that UGIB accounts for 100-200 per 100,000 cases versus 20-27 per 100,000 cases for LGIB. Approximately 85% of lower gastrointestinal bleeding involves the colon, 10% are from bleeds that are actually upper gastrointestinal bleeds, and 3 - 5% involve the small intestines. The mortality rate for LGIB is between 2-4%.
Presentation
A lower Gastrointestinal Bleed is referred as any bleed that occures distal to the ligament of Treitz and superior to the anusAnus
The anus is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, unwanted semi-solid matter produced during digestion, which, depending on the type of animal, may be one or more of: matter which the animal cannot digest,...
. This includes the last 1/4 of the duodenum
Duodenum
The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...
and the entire area of the jejunum
Jejunum
The jejunum is the middle section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms middle intestine or mid-gut may be used instead of jejunum.The jejunum lies between the duodenum...
, ileum
Ileum
The ileum is the final section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms posterior intestine or distal intestine may be used instead of ileum.The ileum follows the duodenum...
, colon
Colon (anatomy)
The colon is the last part of the digestive system in most vertebrates; it extracts water and salt from solid wastes before they are eliminated from the body, and is the site in which flora-aided fermentation of unabsorbed material occurs. Unlike the small intestine, the colon does not play a...
, rectum
Rectum
The rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long...
, and anus.
The stool
Human feces
Human feces , also known as a stool, is the waste product of the human digestive system including bacteria. It varies significantly in appearance, according to the state of the digestive system, diet and general health....
of a person with a lower gastrointestinal bleed is a good (but not infallible) indication of where the bleeding is occurring. Black tarry appearing stools medically referred to as Melena
Melena
In medicine, melena or melaena refers to the black, "tarry" feces that are associated with gastrointestinal hemorrhage. The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon.-Melena vs...
usually indicates blood that has been in the GI tract for at least 8 hours. Melena is four-times more likely to come from an upper gastrointestinal bleed than from the lower GI tract; however, it can also occur in either the duodenum and jejunum, and occasionally the portions of the small intestine
Small intestine
The small intestine is the part of the gastrointestinal tract following the stomach and followed by the large intestine, and is where much of the digestion and absorption of food takes place. In invertebrates such as worms, the terms "gastrointestinal tract" and "large intestine" are often used to...
and proximal colon. Bright red stool, called hematochezia
Hematochezia
Hematochezia is the passage of fresh blood per anus, usually in or with stools . Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper GI bleed...
, is the sign of a fast moving active GI bleed. The bright red or Maroon color is due to the short time taken from the site of the bleed and the exiting at the anus. The presence of hematochezia is six-times greater in a LGIB than with a UGIB.
Occasionally, a person with a LGIB will not present with any signs of internal bleeding. In these cases, a diagnostic assessment or pre-assessment should watch for other signs and symptoms that the patient may present with. These include, but are not limited to, hypotension
Hypotension
In physiology and medicine, hypotension is abnormally low blood pressure, especially in the arteries of the systemic circulation. It is best understood as a physiologic state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. Hypotension is the...
, tachycardia
Tachycardia
Tachycardia comes from the Greek words tachys and kardia . Tachycardia typically refers to a heart rate that exceeds the normal range for a resting heart rate...
, angina
Angina
Angina pectoris, commonly known as angina, is chest pain due to ischemia of the heart muscle, generally due to obstruction or spasm of the coronary arteries . Coronary artery disease, the main cause of angina, is due to atherosclerosis of the cardiac arteries...
, syncope
Syncope (medicine)
Syncope , the medical term for fainting, is precisely defined as a transient loss of consciousness and postural tone characterized by rapid onset, short duration, and spontaneous recovery due to global cerebral hypoperfusion that most often results from hypotension.Many forms of syncope are...
, weakness
Weakness
Weakness is a symptom represented, medically, by a number of different conditions, including: lack of muscle strength, malaise, dizziness, or fatigue. The causes are many and can be divided into conditions that have true or perceived muscle weakness. True muscle weakness is a primary symptom of a...
, confusion
ConFusion
ConFusion is an annual science fiction convention organized by the Stilyagi Air Corps and its parent organization, the Ann Arbor Science Fiction Association. Commonly, it is held the third weekend of January. It is the oldest science fiction convention in Michigan, a regional, general SF con...
, stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
, myocardial infarction
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
/heart attack, and shock.
Causes
- CoagulopathyCoagulopathyCoagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
- specifically a bleeding diathesisBleeding diathesisIn medicine , bleeding diathesis is an unusual susceptibility to bleeding mostly due to hypocoagulability, in turn caused by a coagulopathy . Several types are distinguished, ranging from mild to lethal... - ColitisColitisIn medicine, colitis refers to an inflammation of the colon and is often used to describe an inflammation of the large intestine .Colitides may be acute and self-limited or chronic, i.e...
- ischaemic colitis
- ulcerative colitisUlcerative colitisUlcerative colitis is a form of inflammatory bowel disease . Ulcerative colitis is a form of colitis, a disease of the colon , that includes characteristic ulcers, or open sores. The main symptom of active disease is usually constant diarrhea mixed with blood, of gradual onset...
- infectious colitis
- E. coli O157:H7
- ShigellaShigellaShigella is a genus of Gram-negative, nonspore forming, non-motile, rod-shaped bacteria closely related to Escherichia coli and Salmonella. The causative agent of human shigellosis, Shigella causes disease in primates, but not in other mammals. It is only naturally found in humans and apes. During...
- SalmonellaSalmonellaSalmonella is a genus of rod-shaped, Gram-negative, non-spore-forming, predominantly motile enterobacteria with diameters around 0.7 to 1.5 µm, lengths from 2 to 5 µm, and flagella which grade in all directions . They are chemoorganotrophs, obtaining their energy from oxidation and reduction...
- Campylobacter jejuniCampylobacter jejuniCampylobacter jejuni is a species of curved, helical-shaped, non-spore forming, Gram-negative, microaerophilic bacteria commonly found in animal feces. It is one of the most common causes of human gastroenteritis in the world. Food poisoning caused by Campylobacter species can be severely...
- Hemorrhoids
- AngiodysplasiaAngiodysplasiaIn medicine , angiodysplasia is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places...
- Neoplasm - cancer
- Diverticular disease - diverticulosis, diverticulitis
The following are possible diagnosis of a LGIB:
- Hemorrhoids are a common occurrence; however, rarely they have been known to rupture and result in a massive hemorrhage. Causes for this include frequent or chronic constipation, straining to have a bowel movement, diets low in fiber, and pregnancy. It may present with small amounts of bright red bleeding.
- Anal fissures
- Rectal foreign bodies
- Ulcerative colitisUlcerative colitisUlcerative colitis is a form of inflammatory bowel disease . Ulcerative colitis is a form of colitis, a disease of the colon , that includes characteristic ulcers, or open sores. The main symptom of active disease is usually constant diarrhea mixed with blood, of gradual onset...
- Crohn's diseaseCrohn's diseaseCrohn's disease, also known as regional enteritis, is a type of inflammatory bowel disease that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms...
- Pseudomembranous colitisPseudomembranous colitisPseudomembranous colitis, a cause of antibiotic-associated diarrhea , is an infection of the colon. It is often, but not always, caused by the bacterium Clostridium difficile. Because of this, the informal name C. difficile colitis is also commonly used. The illness is characterized by...
- Infectious diarrheaInfectious diarrheaInfectious diarrhea or Contagious diarrhea may be defined as diarrhea caused by an infection of the digestive system by a bacterium, virus, or parasite that results in frequent bowel motions producing excessive amounts of liquidy feces.-Causes:...
- Radiation colitis
- DiverticulosisDiverticulosisDiverticulosis also known as "diverticular disease" is the condition of having diverticula in the colon, which are outpocketings of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. These are more common in the sigmoid colon, which is a common place for...
- Mesenteric ischemiaMesenteric ischemiaMesenteric ischemia is a medical condition in which inflammation and injury of the small intestine result from inadequate blood supply. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot...
- colonic polyps
- colon cancer
Diagnosis
Triage
Triage or ) is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate,...
nurse, emergency department nurse, and/or a physician or other clinican. The initial assessment will include the appearance of the individual, their vital signs, and mental status. A patient history will help reveal a disposition or history of LGIBs or potential differential diagnosis.
Orthostatic vital signs
Orthostatic vital signs
Orthostatic vital signs are a series of vital signs of a patient taken standing, supine and sometimes sitting to form a baseline for analysis and comparison...
are often used as an indicator of hypovolemia.
Laboratory test will also help give indications of a LGIB. Hemoglobin
Hemoglobin
Hemoglobin is the iron-containing oxygen-transport metalloprotein in the red blood cells of all vertebrates, with the exception of the fish family Channichthyidae, as well as the tissues of some invertebrates...
, hematocrit
Hematocrit
The hematocrit or packed cell volume or erythrocyte volume fraction is the percentage of the concentration of red blood cells in blood. It is normally about 45% for men and 40% for women...
, and platelets are very good physical signs of hypovolemia or blood loss anemia. Partial thromboplastin time
Partial thromboplastin time
The partial thromboplastin time or activated partial thromboplastin time is a performance indicator measuring the efficacy of both the "intrinsic" and the common coagulation pathways...
(PTT) and INR
INR
- Codes :INR is:* the ISO 4217 currency code of the Indian rupee * the Federal Aviation Administration location identifier of the McKinley National Park Airport, McKinley Park, Alaska, United States...
will also help determine the body's current ability to clot.
Aspiration
Aspiration
Aspiration may refer to:In linguistics:*Aspirated consonant, a plosive pronounced with a strong burst of air*Debuccalization, the conversion of a consonant to [h] or [ʔ]*Voiceless glottal fricative In engine technology:...
of the stomach contents by way of a nasogastric tube (NG tube) will help differentiate between either a UGIB and a LGIB. A negative presence of blood will help to rule out an UGIB.
Differential diagnosis
A differential diagnosis is a systematic method used to identify unknowns. With the use of a differential diagnosisDifferential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
, physicians or other clinicians begin to rule out what the illness is not to narrow the diagnosis of the specific disease process, as with a lower gastrointestinal bleed.
Diverticulosis, Angiodysplasia, Infectious Colitis, Ischemic Colitis, Inflammatory Bowel Disease, Neoplasms, Radiation Telangiectasia and Proctitis, and NSAID Enteropathy and Colopathy are the causes of LGIB in adults.
The most common cause of massive bleeding in pediatric patients is Meckels Diverticulum. Anorectral disease (hemorrhoids and fissures) causes less severe bleeding in pediatric patients.
Management
Hypovolemia
In physiology and medicine, hypovolemia is a state of decreased blood volume; more specifically, decrease in volume of blood plasma...
they will most likely be placed on a vital sign monitor and administered oxygen either by nasal cannula
Nasal cannula
The nasal cannula is a device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help. This device consists of a plastic tube which fits behind the ears, and a set of two prongs which are placed in the nostrils. Oxygen flows from these prongs...
or simple face mask
Simple face mask
The simple face mask is a basic disposable mask, made of clear plastic, to provide oxygen therapy for patients who are experiencing conditions such as chest pain , dizziness, and minor hemorrhages. It is often set to deliver oxygen between 6-10 litres per minute...
. An intravenous catheter
Intravenous therapy
Intravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
will be placed into an easily accessible area and IV fluids will be administered to replace lost volume.
Surgical intervention
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
is warranted in some cases. It is most likely that a surgical consult
Surgeon
In medicine, a surgeon is a specialist in surgery. Surgery is a broad category of invasive medical treatment that involves the cutting of a body, whether human or animal, for a specific reason such as the removal of diseased tissue or to repair a tear or breakage...
will be ordered if the patient is unable to be stabilized by non-invasive techniques, or a perforation is found that requires surgery.
See also
- Fecal occult bloodFecal occult bloodFecal occult blood refers to blood in the feces that is not visibly apparent. A fecal occult blood test checks for hidden blood in the stool...
- Blood in stoolBlood in stoolIn medicine, when referring to human feces, blood in stool can refer to multiple conditions:* Melena, with more blackish appearance, originating in upper parts of the gastrointestinal tract...
- Rectal bleedingRectal bleedingRectal bleeding can refer to:* Lower gastrointestinal bleeding* Hematochezia* Fecal occult blood* Melena...
- Upper gastrointestinal bleedingUpper gastrointestinal bleedingUpper gastrointestinal bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon.Upper GI bleeds are considered...