Surgical management of lower gastrointestinal bleeding

Review Article



Lower gastrointestinal bleeding (LGIB) is any form of bleeding distal to the Ligament of Treitz. In most cases, acute LGIB is self-limited and resolves spontaneously with conservative management.


Only a minority of approximately 10% is admitted to hospital with signs of massive bleeding and shock requiring resuscitation, urgent evaluation and treatment.


Over the past decade, there has been a progressive decrease in upper GI events and a significant increase in lower GI events. Overall, mortality has also decreased, but in-hospital fatality due to upper or lower GI complications have remained constant. The problem is that LGIB can arise from a number of sources and may be a significant cause of hospitalisation and mortality in elderly patients.


After initial resuscitation, the diagnosis and treatment of LGIB remains a challenge for acute care surgeons, whereby the identification of the source of bleeding is of utmost importance.


Lower GI bleeding Colonoscopy Angiography Surgery 


  1. 1.
    Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc. 1999;49:228–38.PubMedCrossRefGoogle Scholar
  2. 2.
    Lanas A, García-Rodríguez LA, Polo-Tomás M, Ponce M, Alonso-Abreu I, Perez-Aisa MA, et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol. 2009;104:1633–41.PubMedCrossRefGoogle Scholar
  3. 3.
    Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1997;92:419–24.PubMedGoogle Scholar
  4. 4.
    Schiller LR, Lichliter W. Acute lower gastrointestinal bleeding. In: Wexner SD, Stollman N, editors. Diseases of the colon. New York: Informa Healthcare; 2007. p. 364–74.Google Scholar
  5. 5.
    Rollins ES, Picus D, Hicks ME, Darcy MD, Bower BL, Kleinhoffer MA. Angiography is useful in detecting the source of chronic gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol. 1991;156:385–8.PubMedGoogle Scholar
  6. 6.
    Saperas E, Dot J, Videla S, Alvarez-Castells A, Perez-Lafuente M, Armengol JR, et al. Capsule endoscopy versus computed tomographic or standard angiography for the diagnosis of obscure gastrointestinal bleeding. Am J Gastroenterol. 2007;102:731–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Hewitson P, Glasziou P, Watson E, Towler B, Irwig L. Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): an update. Am J Gastroenterol. 2008;103:1541–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Imperiale TF, Ransohoff DF, Itzkowitz SH, Turnbull BA, Ross ME; Colorectal Cancer Study Group. Fecal DNA versus fecal occult blood for colorectal-cancer screening in an average-risk population. N Engl J Med. 2004;351:2704–14.PubMedCrossRefGoogle Scholar
  9. 9.
    Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin. 2010;60:277–300.PubMedCrossRefGoogle Scholar
  10. 10.
    Levin B, Lieberman DA, McFarland B, Smith RA, Brooks D, Andrews KS, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on colorectal cancer and the American College of Radiology. CA Cancer J Clin. 2008;58:130–60.PubMedCrossRefGoogle Scholar
  11. 11.
    Pennoyer W, Jeffrey C. Diverticular hemorrhage. In: Welch JP, Cohen JL, Sardella WV, Vignati PV, editors. Diverticular disease. Baltimore: Williams & Wilkins; 1998. p. 76–94.Google Scholar
  12. 12.
    Farrands PA, Taylor I. Management of acute lower gastrointestinal haemorrhage in a surgical unit over a 4-year period. J R Soc Med. 1987;80:79–82.PubMedGoogle Scholar
  13. 13.
    Bai Y, Peng J, Gao J, Zou DW, Li ZS. Epidemiology of lower gastrointestinal bleeding in China: single-center series and systematic analysis of Chinese literature with 53,951 patients. J Gastroenterol Hepatol. 2011;26:678–82.PubMedCrossRefGoogle Scholar
  14. 14.
    Tonea A, Andrei S, Andronesi D, Ionescu M, Gheorghe C, Herlea V, et al. Difficulties in diagnosis and surgical treatment of the angiodysplasia of the gastrointestinal tract. Chirurgia (Bucur). 2008;103:513–28.Google Scholar
  15. 15.
    Golitz LE. Heritable cutaneous disorders which affect the gastrointestinal tract. Med Clin North Am. 1980;64:829–46.PubMedGoogle Scholar
  16. 16.
    Francois F, Tadros C, Diehl D. Pan-colonic varices and idiopathic portal hypertension. J Gastrointestin Liver Dis. 2007;16:325–8.PubMedGoogle Scholar
  17. 17.
    Baichi MM, Arifuddin RM, Mantry PS. Gastrointestinal bleeding in a patient with Ehlers–Danlos syndrome: an endoscopic dilemma. Dig Dis Sci. 2005;50:1342–3.PubMedCrossRefGoogle Scholar
  18. 18.
    Sorbi D, Norton I, Conio M, Balm R, Zinsmeister A, Gostout CJ. Postpolypectomy lower GI bleeding: descriptive analysis. Gastrointest Endosc. 2000;51:690–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Buddingh KT, Herngreen T, Haringsma J, van der Zwet WC, Vleggaar FP, Breumelhof R, et al. Location in the right hemi-colon is an independent risk factor for delayed post-polypectomy hemorrhage: a multi-center case–control study. Am J Gastroenterol. 2011 Jan 25; doi:10.1038/ajg.2010.507. PubMed PMID: 21266961.
  20. 20.
    Ciccarelli O, Coley GM. Massive rectal bleeding in Crohn’s colitis. Conn Med. 1986;50:301–3.PubMedGoogle Scholar
  21. 21.
    Huang CC, Wang IF, Chiu HH. Lower gastrointestinal bleeding caused by stercoral ulcer. CMAJ. 2011;183(2):E134. PubMed PMID: 21173065.PubMedCrossRefGoogle Scholar
  22. 22.
    Rahme E, Bernatsky S. NSAIDs and risk of lower gastrointestinal bleeding. Lancet. 2010;376:146–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Batt M, Jean-Baptiste E, O’Connor S, Saint-Lebes B, Feugier P, Patra P, et al. Early and late results of contemporary management of 37 secondary aortoenteric fistulae. Eur J Vasc Endovasc Surg. 2011;41:748–757. PubMed PMID: 21414817.PubMedCrossRefGoogle Scholar
  24. 24.
    Gayer C, Chino A, Lucas C, Tokioka S, Yamasaki T, Edelman DA, et al. Acute lower gastrointestinal bleeding in 1,112 patients admitted to an urban emergency medical center. Surgery. 2009;146:600–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Mellinger JD, Bittner JG 4th, Edwards MA, Bates W, Williams HT. Imaging of gastrointestinal bleeding. Surg Clin North Am. 2011;91:93–108.PubMedCrossRefGoogle Scholar
  26. 26.
    Zuckerman DA, Bocchini TP, Birnbaum EH. Massive hemorrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention. AJR Am J Roentgenol. 1993;161:703–11.PubMedGoogle Scholar
  27. 27.
    Gillespie CJ, Sutherland AD, Mossop PJ, Woods RJ, Keck JO, Heriot AG. Mesenteric embolization for lower gastrointestinal bleeding. Dis Colon Rectum. 2010;53:1258–64.PubMedCrossRefGoogle Scholar
  28. 28.
    Kennedy DW, Laing CJ, Tseng LH, Rosenblum DI, Tamarkin SW. Detection of active gastrointestinal hemorrhage with CT angiography: a 4(1/2)-year retrospective review. J Vasc Interv Radiol. 2010;21:848–55.PubMedCrossRefGoogle Scholar
  29. 29.
    Stathaki MI, Karkavitsas NS. Nuclear medicine in the diagnosis of lower gastrointestinal bleeding. Hell J Nucl Med. 2007;10:197–204.PubMedGoogle Scholar
  30. 30.
    Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol. 2010;8:333–43.PubMedCrossRefGoogle Scholar
  31. 31.
    Hunter JM, Pezim ME. Limited value of technetium 99m-labeled red cell scintigraphy in localization of lower gastrointestinal bleeding. Am J Surg. 1990;159:504–6.PubMedCrossRefGoogle Scholar
  32. 32.
    Lee J, Costantini TW, Coimbra R. Acute lower GI bleeding for the acute care surgeon: current diagnosis and management. Scand J Surg. 2009;98:135–42.PubMedGoogle Scholar
  33. 33.
    Tan KK, Wong D, Sim R. Superselective embolization for lower gastrointestinal hemorrhage: an institutional review over 7 years. World J Surg. 2008;32:2707–15.PubMedCrossRefGoogle Scholar
  34. 34.
    Haemorrhage, hypovolaemia, shock. In: Cuschieri A, Grace PA, Darzi A, Borley N, Rowley DI, editors. Clinical surgery. 2nd ed. Oxford: Blackwell Science Ltd.; 2003. p. 136–47.Google Scholar
  35. 35.
    Chen CY, Wu CC, Jao SW, Pai L, Hsiao CW. Colonic diverticular bleeding with comorbid diseases may need elective colectomy. J Gastrointest Surg. 2009;13:516–20.PubMedCrossRefGoogle Scholar
  36. 36.
    Gianfrancisco JA, Abcarian H. Pitfalls in the treatment of massive lower gastrointestinal bleeding with “blind” subtotal colectomy. Dis Colon Rectum. 1982;25:441–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Drapanas T, Pennington DG, Kappelman M, Lindsey ES. Emergency subtotal colectomy: preferred approach to management of massively bleeding diverticular disease. Ann Surg. 1973;177:519–26.PubMedCrossRefGoogle Scholar
  38. 38.
    Welch CE, Athanasoulis CA, Galdabini JJ. Hemorrhage from the large bowel with special reference to angiodysplasia and diverticular disease. World J Surg. 1978;2:73–83.PubMedCrossRefGoogle Scholar
  39. 39.
    Eaton AC. Emergency surgery for acute colonic haemorrhage—a retrospective study. Br J Surg. 1981;68:109–12.PubMedCrossRefGoogle Scholar
  40. 40.
    Colacchio TA, Forde KA, Patsos TJ, Nunez D. Impact of modern diagnostic methods on the management of active rectal bleeding. Ten year experience. Am J Surg. 1982;143:607–10.PubMedCrossRefGoogle Scholar
  41. 41.
    Britt LG, Warren L, Moore OF 3rd. Selective management of lower gastrointestinal bleeding. Am Surg. 1983;49:121–5.PubMedGoogle Scholar
  42. 42.
    Leitman IM, Paull DE, Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg. 1989;209:175–80.PubMedCrossRefGoogle Scholar
  43. 43.
    Milewski PJ, Schofield PF. Massive colonic haemorrhage—the case for right hemicolectomy. Ann R Coll Surg Engl. 1989;71:253–9.PubMedGoogle Scholar
  44. 44.
    Bender JS, Wiencek RG, Bouwman DL. Morbidity and mortality following total abdominal colectomy for massive lower gastrointestinal bleeding. Am Surg. 1991;57:536–40.PubMedGoogle Scholar
  45. 45.
    Setya V, Singer JA, Minken SL. Subtotal colectomy as a last resort for unrelenting, unlocalized, lower gastrointestinal hemorrhage: experience with 12 cases. Am Surg. 1992;58:295–9.PubMedGoogle Scholar
  46. 46.
    Parkes BM, Obeid FN, Sorensen VJ, Horst HM, Fath JJ. The management of massive lower gastrointestinal bleeding. Am Surg. 1993;59:676–8.PubMedGoogle Scholar
  47. 47.
    McGuire HH Jr. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg. 1994;220:653–6.PubMedCrossRefGoogle Scholar
  48. 48.
    Baker R, Senagore A. Abdominal colectomy offers safe management for massive lower GI bleed. Am Surg. 1994;60:578–81.PubMedGoogle Scholar
  49. 49.
    Schilling MK, Scheurer U, Büchler MW. Lower gastrointestinal hemorrhage: etiologic assessment and surgical concept. Zentralbl Chir. 1998;123:1400–4.PubMedGoogle Scholar
  50. 50.
    Farner R, Lichliter W, Kuhn J, Fisher T. Total colectomy versus limited colonic resection for acute lower gastrointestinal bleeding. Am J Surg. 1999;178:587–91.PubMedCrossRefGoogle Scholar
  51. 51.
    García-Osogobio S, Remes-Troche JM, Takahashi T, Barreto Camilo J, Uscanga L. Surgical treatment of lower digestive tract hemorrhage. Experience at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Rev Invest Clin. 2002;54:119–24.PubMedGoogle Scholar
  52. 52.
    Renzulli P, Maurer CA, Netzer P, Dinkel HP, Büchler MW. Subtotal colectomy with primary ileorectostomy is effective for unlocalized, diverticular hemorrhage. Langenbecks Arch Surg. 2002;387:67–71.PubMedCrossRefGoogle Scholar
  53. 53.
    Klar E, Stöwhas M, Foitzik T. A surgical approach to acute intestinal bleeding. Chirurg. 2006;77:133–8.PubMedCrossRefGoogle Scholar
  54. 54.
    Bokhari M, Vernava AM, Ure T, Longo WE. Diverticular hemorrhage in the elderly—is it well tolerated? Dis Colon Rectum. 1996;39:191–5.PubMedCrossRefGoogle Scholar
  55. 55.
    Sherman LM, Shenoy SS, Cerra FB. Selective intra-arterial vasopressin: clinical efficacy and complications. Ann Surg. 1979;189:298–302.PubMedCrossRefGoogle Scholar
  56. 56.
    Stabile BE, Stamos MJ. Surgical management of gastrointestinal bleeding. Gastroenterol Clin North Am. 2000;29:189–222.PubMedCrossRefGoogle Scholar
  57. 57.
    Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol. 1998;93:1202–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Brandt LJ, Boley SJ, Mitsudo S. Clinical characteristics and natural history of colitis in the elderly. Am J Gastroenterol. 1982;77:382–6.PubMedGoogle Scholar
  59. 59.
    Chait MM. Lower gastrointestinal bleeding in the elderly. World J Gastrointest Endosc. 2010;2:147–54.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.Division of General Surgery, Department of Surgery and Section for Surgical ResearchMedical University of GrazGrazAustria

Personalised recommendations