1. Lower Gastrointestinal Bleeding
Kirk Bernadino, M.D.
St. Mary’s / Duluth Clinic
Section of Gastroenterology

2. Upper vs. Lower GI Hemorrhage

3. Upper vs. Lower GI Hemorrhage “What Comes Up Might Go Down”
“Hematemesis doesn’t lie”

4. Causes of Lower GI Bleeding
Upper GI Source – 10%
Small Bowel Source – 5%
Colonic Source – 85%

5. Depth and Bouquet
Hematochezia
Melena

6. Clots Depth and Bouquet Maroon Bright Red Black STINKY! Hematochezia
Melena
Black
STINKY!

7. Etiologies of Lower GI Bleeding
Diverticular hemorrhage
Cancer / Polyps
Angiodysplasia
Colitis
Anorectal
Meckel’s Diverticulum
Misc.

8. Etiologies of Lower GI Bleeding
Cancer / Polyps
Colon / Rectal
Carcinoid
Appendiceal
Small bowel
Metastatic

9. Etiologies of Lower GI Bleeding
Colitis
Infectious
Ischemic
Inflammatory
Radiation
Diversion

10. Etiologies of Lower GI Bleeding
Anorectal
Hemorrhoids
Anal Fissure
Solitary Rectal Ulcer
Dieulafoy’s

11. Etiologies of Lower GI Bleeding
Misc.
Postpolypectomy
NSAID ulcers
Anastomotic

12. Etiologies of Lower GI Bleeding
Diverticular hemorrhage
Cancer / Polyps
Angiodysplasia
Infectious
Ischemic
Inflammatory
Hemorrhoids
Anal Fissure
Solitary Rectal Ulcer
Meckel’s Diverticulum
Dieulafoy’s

13. Etiologies of Lower GI Bleeding
Acute Chronic
Diverticular hemorrhage
Cancer / Polyps
Angiodysplasia
Infectious
Ischemic
Inflammatory
Hemorrhoids
Anal Fissure
Solitary Rectal Ulcer
Meckel’s Diverticulum
Dieulafoy’s

14. Etiologies of Lower GI Bleeding
Acute Chronic
Diverticular hemorrhage
Cancer / Polyps
Angiodysplasia
Infectious
Ischemic
Inflammatory
Hemorrhoids
Anal Fissure
Solitary Rectal Ulcer
Meckel’s Diverticulum
Dieulafoy’s

15. Etiologies of Lower GI Bleeding
Massive Minor
Diverticular hemorrhage
Cancer / Polyps
Angiodysplasia
Infectious
Ischemic
Inflammatory
Hemorrhoids
Anal Fissure
Solitary Rectal Ulcer
Meckel’s Diverticulum
Dieulafoy’s

16. Etiologies of Lower GI Bleeding
Massive Minor
Diverticular hemorrhage
Cancer / Polyps
Angiodysplasia
Infectious
Ischemic
Inflammatory
Hemorrhoids
Anal Fissure
Solitary Rectal Ulcer
Meckel’s Diverticulum
Dieulafoy’s

17. Etiologies of Lower GI Bleeding
Old Young
Diverticular hemorrhage
Cancer / Polyps
Angiodysplasia
Infectious
Ischemic
Inflammatory
Hemorrhoids
Anal Fissure
Solitary Rectal Ulcer
Meckel’s Diverticulum
Dieulafoy’s

18. Etiologies of Lower GI Bleeding
Old Young
Diverticular hemorrhage
Cancer / Polyps
Angiodysplasia
Infectious
Ischemic
Inflammatory
Hemorrhoids
Anal Fissure
Solitary Rectal Ulcer
Meckel’s Diverticulum
Dieulafoy’s

19. What is the differential? What is the most likely diagnosis?
Case 1
A 64 year old man presents with intense LLQ pain and fever. Symptoms have worsened over the last 3 days. A CT of the abdomen and pelvis reveal intense pelvic inflammation with a round structure containing fluid density and air.
What is the differential? What is the most likely diagnosis?

21. Diverticulitis & Diverticular hemorrhage

27. Diverticular Disease of the Colon
In the West, affects 5-10% > age 40 and 80% > age 85.
Symptoms of diverticulitis occur in about 20%
Symptoms: Pain, diarrhea, fever & abdominal tenderness
Diverticulitis may rupture or may fistulize to adjacent organs
Diverticulitis does not increase risk of hemorrhage
Diagnosis is made by CT, not endoscopy or barium enema

29. Treatment of Diverticulitis
Mild
without peritoneal signs, tolerating po:
oral hydration, liquid diet,
oral antibiotics
Severe
peritonitis, cannot tolerate PO:
hospitalize, IV antibiotics, NPO, CT scan
Emergent
Peritonitis; sepsis; perforation
surgical intervention

30. Case 2
A 76 year old man presents to the emergency room having become dizzy after passing a large painless bloody stool. In the ER he again passes a voluminous bright red stool with clots and again feels dizzy. Aside from a BP of 90/56 and a pulse of 110 his physical exam is remarkable only for blood in the rectum.
Hgb = 11.2g
What is the differential? What is most likely?

32. Think!
Small Bowel

38. Diverticular Hemorrhage
50% of acute lower GI bleeding
Massive bleeding occurs in 5% of patients with diverticulosis
75% stop spontaneously
Bleeding recurs in 30%
Risk of rebleeding after a 2nd bleed is > 50%

39. Case 3
An 84 year old woman with renal failure presents to the ER with a 2 day history of copious rectal bleeding confirmed by physical exam. Hgb = 7.4 and she is transfused 2 units packed red cells after complaining of shortness of breath.
What would you like to know? What is the differential?

42. Capsule Endoscopy

45. Arteriovenous Malformations
Vascular ectasias not associated with multisystem disorders
Usually < 5mm in diameter
Most commonly found in the right colon; can occur anywhere in the colon and in the stomach and small intestine
< 10% with AVM’s will have bleeding
Can present as hemorrhage or anemia without overt bleeding

47. Distribution of Angiodysplasia

48. Bleeding Can Occur from Polyps

49. Bleeding from Tumors

50. Case 4
A 68 year old man with severe coronary artery disease, claudication and a 6 month history of intermittent abdominal pain presents to the ER with a history of severe lower abdominal pain followed an hour later by passage of bright red blood per rectum.
What are the key elements of this story?

51. Ischemic Colitis

53. Hemorrhoids

55. Radiation Proctitis

56. Infectious Colitis

57. Solitary Rectal Ulcer

58. Case 5
A 15 year old boy presents to the ER with a first ever episode of severe rectal bleeding. He is dizzy and his Hgb = 10.3g. He has no pain but has cramps just before a BM.
The diagnosis is made on a bleeding scan.

59. Meckel’s Diverticulum