Lower gastrointestinal (GI) bleeding management

Lower gastrointestinal (GI) bleeding refers to bleeding arising distal to the ligament of Treitz. Acute, painless lower GI bleeding in older adults is most commonly caused by colonic diverticula or angiodysplasia. Approximately 10% of patients presenting with rapid rectal bleeding have an upper GI source.

Clinical presentation

Painless haematochezia.
Massive rectal bleeding.
Chronic blood loss.
Occult blood in stool.
Bloody diarrhoea.
Tenesmus.
Abdominal pain.
Fever.
Signs of haemodynamic instability in severe bleeding.

Differential diagnosis of lower GI bleeding

Presentation	Diagnosis
Painless, self-limited, massive haematochezia	Diverticular bleeding (most common overall cause)
Chronic blood loss or acute painless haematochezia in an older adult patient	Angiodysplasia
Stool positive for occult blood in an asymptomatic patient	Colonic polyp or cancer
Risk factors for atherosclerosis and evidence of vascular disease in an older adult patient; typically associated with left lower quadrant abdominal pain	Ischaemic colitis
Aortic stenosis	Angiodysplasia (Heyde syndrome)
History of bloody diarrhoea, tenesmus, abdominal pain, and fever	Inflammatory bowel disease (IBD)
Rapid upper GI bleeding	Dieulafoy lesion (large, tortuous, submucosal arteriole)
Large hiatal hernia	Cameron lesion (mucosal erosions)
Recent liver or biliary procedure	Hemobilia
Necrotizing pancreatitis	Hemosuccus pancreaticus (bleeding from the pancreas)
Previous aortic aneurysm repair	Aortoenteric fistula
Painless haematochezia in a young patient with normal upper endoscopy and colonoscopy	Meckel diverticulum
Mucocutaneous telangiectasias	Hereditary haemorrhagic telangiectasia

Initial assessment and stabilization

Assess haemodynamic status

Assess vital signs and evidence of ongoing blood loss.
Identify haemodynamic instability and signs of shock.

Resuscitation

If the patient is haemodynamically unstable, initiate resuscitation before diagnostic studies are performed.

Consider outpatient follow-up or early discharge when

Patient age <60 years.
No haemodynamic instability.
No evidence of gross rectal bleeding.
An obvious anorectal source of bleeding has been identified.

Investigations

Endoscopic evaluation

Colonoscopy is recommended early, usually within the first 48 hours of admission.

Non-pharmacological management

Most episodes of lower GI bleeding resolve spontaneously.

Endoscopic and interventional management

Endoscopic therapy

Endoscopic therapy should be used to control ongoing bleeding when an identifiable bleeding source is found during colonoscopy.

Interventional radiology or surgery

If colonoscopy does not identify a discrete lesion, or if endoscopic therapy fails to control bleeding, interventional angiography or surgery may be indicated.

Management of Heyde syndrome

Patients with angiodysplasia associated with aortic stenosis (Heyde syndrome) may benefit from valve replacement surgery.

NoteAccording to expert opinion, the blood transfusion threshold for patients with colonic bleeding is a haemoglobin value <9 g/dL.This threshold differs from the evidence-based transfusion threshold used for upper GI bleeding.

Imeandikwa:

Jumatatu, 22 Juni 2026, 12:09:08 UTC

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