- Accounts for 20% cases of acute gastrointestinal haemorrhage
- Most patients are elderly
- Most cases settle spontaneously without the need for emergency surgery
- Following investigation often a cause is nor found
Causes
- Diverticular disease
- Angiodysplasia
- Inflammatory bowel disease
- Ischaemic colitis
- Infective colitis
- Colorectal carcinoma
Angiodysplasia
- Acquired malformation of intestinal blood vessels
- 80% lesions occur in the right side of the colon
- Often associated with cardiac valvular disease
- Dilated vessels or 'cherry red' areas may be seen at colonoscopy
- Early filling of vessels seen at angiography
- Bleeding may be visible during capillary phase of angiogram
- Angiodysplasia is an incidental finding during 5% of colonoscopies
- Seen in up to 25% of asymptomatic patients over the age of 75 years
Investigation
- Most patients are stable and can be investigated once bleeding has stopped
- In the actively bleeding patient consider:
- Colonoscopy - can be difficult
- Selective mesenteric angiography
- May show angiodysplastic lesions even once bleeding has ceased
- Radionuclide scanning
- Uses technetium-99m labeled red blood cells
Rate of bleeding for detection
| Investigation |
Rate of bleeding (ml/min) |
| Radiolabel red cell scan |
0.1 |
| Mesenteric angiography |
1.0 |
| Non-selective aortic angiography |
6.0 |
| Colonoscopy |
Any |
| Intraoperative endoscopy |
Any |
Management
- Acute bleeding tends to be self limiting
- Consider selective mesenteric embolisation if life threatening haemorrhage
- If bleeding persists perform endoscopy to exclude upper GI cause
- Proceed to laparotomy and consider on-table lavage an panendoscopy
- If right-sided angiodysplasia perform a right hemicolectomy
- If bleeding diverticular disease perform a sigmoid colectomy
- If source of colonic bleeding unclear perform a subtotal colectomy and end-ileostomy
Bibliography
Billingham R P. The conundrum of lower gastrointestinal
bleeding. Surg Clin North Am 1997;
77: 241-252.
Ghosh S. Watts D, Kinnear M. Management of gastrointestinal haemorrhage. Postgrad Med J 2002;
78: 4-14.
Vernava A M, Moore B A, Longo
W E, Johnson F E. Lower gastrointestinal bleeding. Dis Colon Rectum 1997;
40: 846-858. |