Management of 
Lower GI Bleeding

1. Management ofManagement of
Lower GI BleedingLower GI Bleeding
Johannes Koch, MD
Digestive Disease Institute

2. Objectives
• Identify high(er) risk patients with LGIB
• Understand the role of medical therapy
for patients with LGIB
• Understand the role of endoscopic/
interventional radiologic therapy for GIB
• Provide the optimal management of
patients with LGIB

3. © 2014 Virginia Mason Medical Center
Lower GI Bleeding Case 1
A 58-year-old man is evaluated in the emergency department for painless
bright red blood per rectum that began 3 hours ago. The bleeding was
accompanied by a syncopal episode. He has a history of rheumatoid
arthritis. His current medications are adalimumab, methotrexate, and
ibuprofen.
On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure
is 88/58 mm Hg, pulse rate is 132/min, and respiration rate is 24/min.
Abdominal examination is normal. Rectal examination discloses bright red
blood in the rectal vault. Nasogastric tube aspirate shows no evidence of
blood or coffee-ground material.
Laboratory studies: hemoglobin level 7.3 g/dL (73 g/L).
Emergency intravenous fluid resuscitation is begun.
Which of the following is the most appropriate diagnostic test to perform
next?
A Colonoscopy
B CT Bleeding study
C Upper endoscopy
D Video capsule endoscopy

4. © 2014 Virginia Mason Medical Center
Lower GI Bleeding Case 2
A 65-year-old man is evaluated in the emergency department for painless
bright red blood per rectum that began 6 hours ago. He has no other
medical problems and takes no medications.
On physical examination, temperature is 36.6 °C (97.9 °F), blood
pressure is 130/78 mm Hg, pulse rate is 96/min, and respiration rate is
18/min. Abdominal examination is normal. Rectal examination discloses
no external hemorrhoids; bright red blood is noted in the rectal vault.
Laboratory studies: hemoglobin level 10.4 g/dL (104 g/L), leukocyte
count 6000/µL (6 × 109
/L), & platelet count 380,000/µL (380 × 109
/L).
Which of the following is the most likely cause of this patient's bleeding?
A Colon cancer
B Diverticulosis
C Duodenal ulcer
D Ischemic colitis

5. © 2014 Virginia Mason Medical Center
Lower GI Bleeding
• 20-27 hospitalizations per 100,000
population/year
• Risk increases with age (200 fold 3rd -9th
decade)
• Mortality 3-14%
• 20% of all episodes of GI bleeding
requiring hospitalization are LGIB
• Endoscopic therapy is not the primary
treatment

6. © 2014 Virginia Mason Medical Center
Lower GI Bleeding
• Diverticular
• Ischemic colitis
• Vascular Ectasias
• Hemorrhoids
• Other
 IBD
 Neoplasms
 Infectious colitis
 NSAIDs and ulcers
 Dieulafoy
 Colonic varices

7. © 2014 Virginia Mason Medical Center
Clinical Presentation of GIB
Upper Lower
Presentation
Hematemesis,
Melena
Hematochezia,
Melena
NG/OG lavage
Blood, Coffee
grounds, Clear
Clear
BUN/Cr Often >36 NL
Bowel sounds Hyperactive NL

8. © 2014 Virginia Mason Medical Center
Outcomes UGIB vs LGIB
Outcome UGIB LGIB
Mortality 5.5% 8.8%
Avg LOS 7.9 d 11.6 d
Avg # tests 0.98 1.26
Strategies EGD many
Prediction rules 25+ 3

9. © 2014 Virginia Mason Medical Center
Risk Factors for LGIB
• Hemodynamic instability
– Hypotension
– Tachycardia
– Syncope
– Orthostasis
• Ongoing bleeding
– Ongoing hematochezia
• Comorbid illnesses
– Age
– Secondary bleeding
– Anticoagulation
– H/o Diverticular, AVM
– Nontender abdomen
– Anemia (Hct <35)
– Elevated Cr
– Abnormal WBC
Kollet Crit Care Med 1995; Strate Arch Int Med 2003;
Das Lancet 2003; Velayos Clin Gast Hep 2004

10. © 2014 Virginia Mason Medical Center
Risk Factors for LGIB
• HCT < 35
• Tachycardia
• Hypotension
• Gross blood on rectal exam
• Comorbid conditions
Kollet Crit Care Med 1995; Strate Arch Int Med 2003;
Das Lancet 2003; Velayos Clin Gast Hep 2004

11. © 2014 Virginia Mason Medical Center
Risk Score LGIB
Predictors of severe bleeding
– Hypotension (SBP<115)
– Tachycardia (>100)
– Syncope
– Nontender abdomen
– Bleeding in <4 hrs
– ASA use
– > 2 comorbid
No of
Predictor
>3
1-3
None
Strate Arch Int Med 2003;
Risk of
Bleeding
85%
45%
10%

12. © 2014 Virginia Mason Medical Center
Urgent Colonoscopy
Outcome Medical
Endoscopy
Hemostasis 0 10
Recurrent 15 0
Surgery 15 0
LOS 5 d 2 d
Jensen et al. NEJM 2000;342:78

13. © 2014 Virginia Mason Medical Center
Urgent Procedure
Procedure Mean time to
exam
Colonoscopy 17 hrs
RBC Scan 8
Angiography 14
CT Bleeding study hours
Strate Am J Gastro 2003; 98:317

14. © 2014 Virginia Mason Medical Center
Lower GI Bleeding
A n g io g r a p h y
f o r r e c u r r e n t
b le e d in g
A n g io g r a p h y
f o r r e c u r r e n t
B le e d in g
C o n s id e r
E G D
C a p s u le
R e p e a t c o lo n o s c o p y
N o s o u r c e S o u r c e
E n d o s c o p ic T x
C o lo n o s c o p y
w it h in 2 4 - 3 6 h r s
L o w r is k / I n a c t iv e
S t a b le
N o S o u r c e S o u r c e
E m b o liz a t io n
R B C S c a n
A n g io C T
|
A n g io g r a p h y
O n g o in g b le e d in g
S u r g e r y c o n s u lt
r / o U p p e r G I
H ig h r is k
P e r s is t e n t b le e d in g
E v a lu a t e , R e s u s c it a te ,
R is k S t r a t if y

15. Gastrointestinal Bleeding
Summary
• Identify high risk patients- ICU, GI
consult
• Optimize Medical Management
• Endoscopic within 24 hours for UGIB
• For ongoing LGIB - consider
angiography
• Coordinate care to optimize
outcomes

16. © 2014 Virginia Mason Medical Center
Lower GI Bleeding Case 1
A 58-year-old man is evaluated in the emergency department for painless
bright red blood per rectum that began 3 hours ago. The bleeding was
accompanied by a syncopal episode. He has a history of rheumatoid
arthritis. His current medications are adalimumab, methotrexate, and
ibuprofen.
On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure
is 88/58 mm Hg, pulse rate is 132/min, and respiration rate is 24/min.
Abdominal examination is normal. Rectal examination discloses bright red
blood in the rectal vault. Nasogastric tube aspirate shows no evidence of
blood or coffee-ground material.
Laboratory studies reveal a hemoglobin level of 7.3 g/dL (73 g/L).
Emergency intravenous fluid resuscitation is begun.
Which of the following is the most appropriate diagnostic test to perform
next?
A Colonoscopy
B CT Bleeding study
C Upper endoscopy
D Video capsule endoscopy

17. © 2014 Virginia Mason Medical Center
Lower GI Bleeding Case 2
A 65-year-old man is evaluated in the emergency department for painless
bright red blood per rectum that began 6 hours ago. He has no other
medical problems and takes no medications.
On physical examination, temperature is 36.6 °C (97.9 °F), blood
pressure is 130/78 mm Hg, pulse rate is 96/min, and respiration rate is
18/min. Abdominal examination is normal. Rectal examination discloses
no external hemorrhoids; bright red blood is noted in the rectal vault.
Laboratory studies reveal a hemoglobin level of 10.4 g/dL (104 g/L), a
leukocyte count of 6000/µL (6 × 109/L), and a platelet count of
380,000/µL (380 × 109/L).
Which of the following is the most likely cause of this patient's bleeding?
A Colon cancer
B Diverticulosis
C Duodenal ulcer
D Ischemic colitis

18. Thank you!Thank you!