This document provides an overview of the evaluation and management of lower gastrointestinal bleeding. It notes that lower GI bleeds typically present with hematochezia or maroon stool. Common causes include angiodysplasia, diverticular disease, colon polyps or cancer, and hemorrhoids. The evaluation involves a focused history, physical exam including rectal exam, and initial labs. Stable patients may be observed, while unstable or high-risk patients require fluid resuscitation and possible blood transfusion or endoscopic intervention. There is no single approach, and management depends on the individual patient's risk factors and stability.
2. Less straight forward treatment and
disposition pathway than Upper GI Bleeding
Typically patients present with hematochezia
or maroon colored stool
◦ Remember a brisk upper GI bleed can present with
hematochezia
◦ In some cases bleeding in the ascending colon will
present as Melena
80-85% will stop spontaneously
2-4 % will result in death
3. More common
◦ Angiodysplasia
◦ Diverticular disease
◦ Colonic carcinoma or polyp
◦ Hemorrhoids or anal fissure
Less common
◦ Massive upper GI bleeding
◦ Inflammatory bowel disease
◦ Ischaemic colitis
◦ Meckel’s diverticulum
◦ Small bowel disease, e.g. tumor, diverticula,
intussusception
◦ Hemobilia (bleeding from the gallbladder)
◦ Solitary colonic ulcer
4. Ask about previous GI Bleeding
Recent colonoscopy or surgeries
Known Inflammatory Bowel Disease
Bleeding disorders
NSAID, Anticoagulant or Antiplatelet use
Ask about pain which may suggest colitis
Hematochezia which suggests diverticular
bleeding
10-15% of patients who describe severe
hematochezia will have an upper GI source
Change in bowel habits suggesting cancer
5. Hemodynamic instability (hypotension, tachycardia,
orthostasis, syncope)
Persistent bleeding
Significant comorbid illnesses
Advanced age
A prior history of bleeding from diverticulosis or
angiodysplasia
Current aspirin use
Prolonged prothrombin time
A non-tender abdomen
Anemia
An elevated blood urea nitrogen level
An abnormal white blood cell count
6. Rectal Exam
◦ Look for any hemorrhoids at the source of bleeding
◦ Appreciate color and character of stool
Bright red blood vs maroon colored stool
Streaks of blood mixed with stool
Gross blood without stool
Anoscopy
◦ Some physicians will perform anoscopy at the bedside,
discuss this with your attending if you suspect an
internal hemorrhoid as the source of bleeding
Abdominal exam
◦ Tenderness
◦ Distention, Ascites, Stigmata of liver failure?
7. Mimics for hematochezia
◦ Partially chewed/digested red grapes
◦ Red food ie beets
◦ Vaginal bleeding
◦ Gross Hematuria
◦ Buttock lesions
Ingestions that may cause a false positive occult
blood test
◦ Red meat
◦ Turnips
◦ Horseradish
◦ Vitamin C
8. CBC
BMP
Hepatic Function Tests
Coags
HemOccult testing
The only ED imaging the may be useful is a CT Scan Abd Pelvis
with IV Only, this is only indicated in patients WITH abdominal
pain
Never give PO Contrast to a patient with a suspected lower GI
bleed, this will obscure any colonoscopy performed within the
near future
9. Fluids
◦ 500ml to 1 L NS
Type and Screen
Blood Transfusion if indicated
◦ If pt is unstable, hypotensive, and you believe cause
is acute blood loss start “Massive Transfusion
Protocol”
◦ If pt is stable await CBC and type/screen
◦ Obtaining blood can take HOURS if you believe pt
needs blood NOW consider starting O-
Reverse any anticoagulation (Next slide)
10. Dabigatran – Praxbind is now available,
dosing per pharmacy, unsure if this is
stocked in all our hospitals
Rivaroxaban, Apixaban, Edoxaban –
administration of 4 factor PCCC at 50
units/kg
◦ There is no research to support the use of PCCs
however there is currently no alternative
◦ TXA can be given in addition
◦ FFP is not indicated
11.
12. Most common cause of OVERT lower GI
bleeding in adults
Most will stop without intervention
◦ 14-38% will rebleed
About 7% of patients with Diverticulosis will
have a diverticular bleed
The ascending colon is most commonly
responsible 50-90% of the time
Diagnosis is made by Colonoscopy or Nuch
Tech Scan
13. Dilated submucosal veins in the anus
◦ Internal – above the dentate line
◦ External – below the dentate line
Hematochezia results from rupture of an internal
hemorrhoid, almost always painless
Blood typically coats stool at end of defecation
Significant GI Bleeding from hemorrhoids resulting in
hemodynamic instability is exceedingly rare unless the
patient is coagulopathic
Anoscopy can be very helpful in the diagnosis
Treatment
◦ Increase fiber in diet, add Colace or MiraLax
◦ Anusol cream or suppository
◦ Sitz Bath
Refer these patients as an outpt to GI for definitive therapy
14. Typically due to passage of hard stool
Perform rectal inspection, if a fissure is visualized
no digital rectal exam is necessary
◦ Fissures commonly occur either posterior or anterior
midline
◦ Fissures that are non midline raise concern for Crohn's
disease or trauma
Treatment
◦ Bowel Regimen (Colace, Miralax)
◦ Sitz Bath
◦ Topical analgesia (2% lidocaine jelly)
◦ Topical Nifedipine or Nitroglycerin (not typically
prescribed in the ED)
15. Dilated, tortuous submucosal vessels
Uncommon, can be associated with aortic
stenosis, von Willebrand disease and Chronic
Renal Failure
Most commonly seen in the cecum or ascending
colon
Can present as overt hematochezia but more
commonly is seen as chronic blood loss with
mildly Hemoccult positive stools
Treatment consists of endoscopic coagulation,
injection sclerotherapy and argon laser
coagulation
16. 10% of lower GI bleed cases in patients > age
50 are due to colon cancer
Bleeding is due to overlying erosion and
ulceration of a cancerous lesions
Tends to be low grade and recurrent,
classically detected as anemia of unknown
etiology in a male > 50 y.o
17. Occurs in 0.3 to 6.1 % of polypectomies
Can be immediate or delayed
◦ Immediate occurring in 1.5% of polypectomies
◦ Delayed bleeding in up to 2 % of polypectomies
In some cases endoscopy is necessary to stop bleeding
The GI physician who performed the colonoscopy should
be notified immediately
Patients who are having frequent bloody bowel movements
and are becoming hemodynamically unstable will need
immediate intervention
Consultation with General Surgery & IR may also be
necessary
Stabilize unstable patients and consult GI
Stable patients should be watched in the ED for 4-6 hours
and GI recs should be followed
18. Disposition can be difficult or straight
forward
Unstable patients need admission to the Step
Down Unit or ICU
Stable patients may require consultation with
a Gastroenterologist to determine a plan of
care
It is never wrong to observe a patient, give 1-
2 L of fluid and repeat an H&H in 4-6 hours.
19.
20. 80 year old male with no history of GI bleeding,
on coumadin for A fib, presenting with two
episodes of maroon colored stool
Blood pressure is stable, HR slightly tachycardic
H&H is stable, INR is therapeutic at 2.5
Dispo Decision: this is the type of patient who
may be stable but would benefit from admission
He is elderly, on an anticoagulant agent and has
a history of CAD.
Consider risk factors and likelihood of bad
outcome prior to seeing a GI physician
21. 24 year old female presents with two days of
bright red blood per rectum X 2 episodes. Pt
has no history of GI bleed, VSS, H&H is stable,
no blood thinners and no PMhx.
Dispo Decision: this is the type of patient who
can go home after screening lab work. Patient
lacks any risk factors and with a stable H&H
after 48 hours it is unlikely she has a
significant GI bleed. Referral to GI as an
outpatient is appropriate.
22. A 45 year old man presents with one episode of
“gushing” bright red blood after having a bowel
movement. The patient had a colonoscopy 24
hours ago, one polyp was removed. He is
otherwise healthy on no blood thinners
Vital signs and screening labs are normal
Dispo Decision: this is the type of patient who
would benefit from rehydration, 1-2 liters of
fluids, ED Obs , GI Consult, and repeat H&H
You will monitor for recurrence of bleeding,
significant drop in H&H and follow GIs Recs.
23. There is no “cook book” method for all lower
GI Bleeding, consider the patients risk factors
and determine treatment plan based on those
risk factors