Approach to Suspected Lower Gastrointestinal Bleeding

  • Wajeeh SalahEmail author
  • Ashley L. Faulx


Acute lower gastrointestinal bleeding (LGIB) is defined as bleeding that originates beyond the ligament of Treitz and accounts for approximately 20 % of all cases of GI bleeding. Diverticular bleeding is the most common source of acute LGIB in the United States. Other frequently encountered sources of LGIB include colonic ischemia, anorectal sources, neoplasia, angiodysplasia, and colitis. Many of the common causes of LGIB present with characteristic clinical features that point to the diagnosis. Hence, a careful clinical history and physical exam can provide vital clues as to the etiology of bleeding and aid in risk stratifying the patient. Early predictors of severity of LGIB include the presence of tachycardia, hypotension, syncope, nonsteroidal anti-inflammatory drugs (NSAIDs) and anticoagulant use, and rectal bleeding within the first 4 h of evaluation, as well as the absence of abdominal pain. Colonoscopy is the preferred initial procedure for the evaluation and potential treatment of LGIB. Evidence suggests that performing colonoscopy early in the hospital course may improve clinical outcomes. New tools, such as high-definition endoscopes, water-jet irrigation systems, large-bore mechanical suction devices, and endoscopic distal attachment caps, have the ability to improve the identification of small or flat lesions in the colon and thus provide better opportunity for therapeutic intervention. New methods, such as the unprepared hydroflush colonoscopy technique, are being developed in order to expedite the performance of early endoscopy and improve the quality of patient care. Further studies are needed to determine the optimal timing of colonoscopy and its role relative to alternative radiologic and therapeutic modalities.

This chapter includes supplementary videos.


Lower gastrointestinal bleeding Diverticular bleeding Rectal outlet bleeding Colorectal neoplasia Angioectasia Ischemic colitis Urgent colonoscopy 

Supplementary material

Video 6.1

Actively bleeding sigmoid colon diverticulum treated with clip application (MP4 18726 kb)

Video 6.2

Ischemic colitis at the splenic flexure in a hypotensive patient hospitalized with sepsis (MP4 9069 kb)

Video 6.3

Actively bleeding colonic angioectasia hidden between mucosal folds at the hepatic flexure, identified using a cap-fitted colonoscope and treated with argon plasma coagulation (MP4 13613 kb)

Video 6.4

Actively bleeding colonic neoplasia found in the descending colon (MP4 6866 kb)

Video 6.5

Distal rectal ulcer with a pulsating visible vessel and large overlying clot, treated with epinephrine injection and clip application (MP4 16147 kb)

Video 6.6

NSAID-induced colonic ulcer in the descending colon (MP4 8453 kb)


  1. 1.
    Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal bleeding: a population-based study. Am J Gastroenterol. 1997;92:419–24.PubMedGoogle Scholar
  2. 2.
    Lanas L, Garcia-Rodriguez L, Polo-Tomas M, et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol. 2009;104:1633–41.CrossRefPubMedGoogle Scholar
  3. 3.
    Farrell JJ, Friedman LS. Review article: the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther. 2005;21:1281–98.CrossRefPubMedGoogle Scholar
  4. 4.
    Strate LL. Lower GI, bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am. 2005;34:643–64.CrossRefPubMedGoogle Scholar
  5. 5.
    Bloomfeld RS, Rockey DC, Shetzline MA. Endoscopic therapy of acute diverticular hemorrhage. Am J Gastroenterol. 2001;96:2367–72.CrossRefPubMedGoogle Scholar
  6. 6.
    Niikura R, Nagata N, Yamada A, et al. Recurrence of colonic diverticular bleeding and associated risk factors. Colorectal Dis. 2012;14:302–5.CrossRefPubMedGoogle Scholar
  7. 7.
    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.CrossRefPubMedGoogle Scholar
  8. 8.
    Jensen D, Machicado G, Rome J, et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Eng J Med. 2000;342:78–82.CrossRefGoogle Scholar
  9. 9.
    Schmulewitz N, Fisher DA, Rockey DC. Early colonoscopy for acute lower GI bleeding predicts shorter hospitals stay: a retrospective study of experience in a single center. Gastrointest Endosc. 2003;58:841–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Strate L, Ayanian JZ, Kotler G, et al. Risk factors for mortality in lower intestinal bleeding. Clin Gastroenterol Hepatol. 2008;6:1004–10.PubMedCentralCrossRefPubMedGoogle Scholar
  11. 11.
    Green BT, Rockey DC, Portwood G, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005;100:2395–402.CrossRefPubMedGoogle Scholar
  12. 12.
    Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol. 2010;105:2636–41.CrossRefPubMedGoogle Scholar
  13. 13.
    Repaka A, Atkinson M, Faulx AL, et al. Immediate unprepared hydroflush colonoscopy for severe lower GI bleeding: a feasibility study. Gastrointest Endosc. 2012;76:367–73.PubMedCentralCrossRefPubMedGoogle Scholar
  14. 14.
    Barnert J, Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol. 2009;6:637–46.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.Department of GastroenterologyMayo Clinic Health System – Eau ClaireEau ClaireUSA
  2. 2.Division of Gastroenterology and Liver DiseaseUniversity Hospitals Case Medical CenterClevelandUSA

Personalised recommendations