• The majority of patients with lower GI bleeding have a fissure or infection.
• Mucosal lesions are more likely to be associated with antecedent occult bleeding.
• In most of patients the bleeding stops spontaneously.

• Anal fissure
• Necrotizing enterocolitis
• Enteric infections
• Allergic colitis
• Lymphonodular hyperplasia (LNH)
• Upper GI source
• Duplication cyst
• Enterocolitis with Hirschsprung disease
• Meckel diverticulum
• Vascular malformations
• Shock with ischemic bowel
• Hemorrhagic disease of the newborn

• Anal fissure
• Enteric infections
• Allergic colitis
• Intussusception
• Meckel diverticulum
• Lymphonodular hyperplasia (LNH)
• Upper GI source
• Duplication cyst
• Enterocolitis with Hirschsprung disease
• Vascular malformation
• Shock with ischemic bowel
• Gangrenous bowel

• Anal fissure
• Enteric infections
• Polyps
• Parasites
• Meckel diverticulum
• Intussusception
• LNH
• Inflammatory bowel disease (IBD)
• Enterocolitis with Hirschprung disease
• Hemolytic uremic syndrome
• Shock with ischemic bowel
• Gangrenous bowel
• Vascular malformation
• Child abuse

• Anal fissure
• Enteric infections
• IBD
• Intussusception
• Meckel diverticulum
• Polyps
• Henoch Schöenlein purpura (HSP)
• Hemolytic uremic syndrome (HUS)
• Parasites
• Child abuse
• Vascular malformations

• Anal fissure
• Enteric infections
• IBD
• HUS
• Intussusception
• Midgut volvulous
• Vascular malformations
• LNH
• Parasites

• The rate of bleeding will determine the clinical presentation.
• The more rapid the rate, the larger the volume of lower GI bleeding, and greater the drop in hemoglobin and change in pulse and blood pressure.
• Any significant blood loss will lead to pallor, tachycardia, orthostasis, poor capillary refill, CNS changes (restlessness, confusion), and hypotension.
• Hypotension may not be seen even in the face of significant blood loss, because vasoconstriction will occur to maintain blood pressure until decompensation.
• Initial hemoglobin values may be unreliable since a delay in hemodilution may falsely result in near-normal values.
• In newborn, determine if this is swallowed maternal blood.

Question: Is this really blood?
Significance: Get a history and check if any recently ingested foods resemble blood, e.g., red dye, beets, Jell-O, Kool-Aid.

Question: Color of blood
Significance: If bright red then site of bleeding is probably in left colon, rectosigmoid or anal canal, if darker red then from right colon, if melena or tarry then bleeding is proximal to ileocecal valve.

Question: Check location of blood in relation to the stool
Significance: In colitis the blood will be mixed with the stool, with a fissure it will be in streaks on the outer aspect of the stool.

Question: Determine consistency of the stool
Significance: If diarrhea, more likely to be colitis, if hard then more likely to be a fissure.

Question: Painful stools?
Significance: Suggest anal fissure or local proctitis.

Question: Painless rectal bleeding?
Significance: Associated with polyps and Meckel diverticulum.

Question: Abdominal pain?
Significance: Can be seen with colitis, IBD, or surgical abdomen.

Question: Any underlying known GI disease, previous GI surgery?
Significance: Past history of colitis, Hirsch-sprung disease, necrotizing enterocolitis.

Question: Any history of jaundice, hepatitis, liver disease, neonatal history?
Significance: Suggestive of portal vein thrombosis (sepsis, shock, exchange transfusion, omphalitis, IV catheters), portal hypertension, and variceal bleeding.

Question: Any familial history of bleeding diathesis?
Significance: von Willebrand disease, hemophilia

• Any medications that can cause bleeding—heparin, warfarin?
• Any associated symptoms?
  • Mouth ulcers
  • Weight loss
  • Joint pains as in IBD
  • Petechiae
  • Renal insufficiency
  • History of ingestion of uncooked meat as in HUS
  • Purpuric rash as in HSP
  • Severe abdominal pain and vomiting as in a surgical abdomen

Finding: Skin
Significance:

Finding: HEENT: freckles on buccal mucosa
Significance: Peutz-Jeghers syndrome

Finding: Mouth ulcers
Significance: Crohn disease

Finding: Abdomen: hepatosplenomegaly, ascites
Significance: Portal hypertension

Finding: Isolated splenomegaly
Significance: Cavernous transformation of the portal vein

Finding: Rectal examination: evidence of any perianal disease
Significance: Source of bleeding

Test: CBC
Significance: Iron-deficiency anemia. If there is leukopenia, anemia, and thrombocytopenia think chronic liver disease and portal hypertension. If there is anemia with normal RBC indices, then there is truly an acute cause for bleeding. If RBC indices indicate iron-deficiency anemia, think of varices or a mucosal lesion, i.e., chronic blood loss. If thrombocytopenia, think HUS.

Test: Coagulation profile
Significance: If PT/PTT are abnormal then think of liver disease or disseminated intravascular coagulation (DIC) with sepsis. If DIC screen is negative, think liver disease.

Test: Renal function tests (BUN, creatinine, urine analysis)
Significance: Abnormal in HUS, HSP

Test: Liver function tests
Significance: Abnormal in chronic liver disease

Test: Stool tests
Significance: Stool culture (Salmonella, Shigella, Campylobacter, Yersinia, Aeromonas, E. coli), stool for Clostridium difficile toxin A and B, three stool samples for ova and parasites (amoeba). Stool smears for white blood cells (not always positive in colitis) and eosinophils (not always positive in allergic colitis).

Test: Abdominal x-ray
Significance: Helpful in surgical abdomen (dilated bowel, air-fluid levels, perforation), constipation (presence of excessive stool), or colitis (edematous bowel, thumb-printing) and toxic megacolon.

Test: Lower and upper endoscopy
Significance: Full colonoscopy to the terminal ileum helpful in diagnosing IBD. Upper endoscopy diagnostic in massive upper GI bleeds presenting with hematochezia.

Test: Barium tests
Significance: Barium enema is diagnostic and therapeutic in intussusception. Contraindicated in moderate and severe colitis. Air contrast barium enema is helpful in diagnosing mucosal lesions (polyps). Upper GI series with small bowel follow through is helpful in evaluating anatomy and Crohn disease and its complications (fistula, sometimes ulcer may be identified). Enteroclysis or small bowel enema provides good mucosal detail.

Test: Meckel scan
Significance: Diagnostic for Meckel diverticulum that secrete acid. There may be false-negatives if the Meckel diverticulum has different tissue expression.

Test: Bleeding scan
Significance: Useful in the patient in whom endoscopy was not diagnostic. Technetium sulfur colloid versus tagged RBC scan. The former detects rapid bleeding but can miss small bleeds, especially if patient is not bleeding during the scan. The latter can detect small bleeds, especially if intermittent.

Test: Angiography
Significance: Useful in detecting vascular causes for GI bleeding. Can also be therapeutic.

• If patient critical, stabilize the patient with intravenous fluids and blood products.
• Order laboratory tests: CBC, PT/PTT, DIC screen, liver function tests, blood type, and crossmatch.
• Insert an NG tube and lavage with saline if it is unclear whether the patient is having hematochezia due to massive bleeding from the upper GI tract.
• Monitor patient’s vital signs and hemoglobin as necessary.
• Make appropriate diagnosis and institute appropriate therapy, i.e., abdominal x-ray, colonoscopy, bleeding scans.

• Make sure red substance in stool is really blood and not food coloring.
• Initial hemoglobin if normal may be misleading.

Q: What is the most common cause of lower GI bleeding?
A: Throughout all age groups fissures are the leading cause followed by infections. However, in infancy, the most common cause is a fissure, in toddlers and young children—polyps, and in older children—IBD.

Q: What common foods cause stools to be red? black?
A: Red: Raspberries, cranberries, artificial coloring in cereal. Black: Bismuth, licorice.

• Any patient with significant acute lower GI bleeding after initial stabilization
• Patients with less acute bleeding for whom an easily identifiable cause has not been found (e.g., fissures, infection, intussusception, Meckel diverticulum); patients with chronic or recurrent lower GI bleeding.

• Anal fissure: Treat the underlying constipation (mineral oil, lactulose, high-fiber diet). Local therapy consists of sitz baths, local emollient cremes, steroid suppositories.
• Polyp: Colonoscopy and polypectomy
• Intussusception: Barium enema is both diagnostic and permits hydrostatic reduction.
• Parasites.
• Surgery: In cases of massive or persistent bleeding with no identifiable site, exploratory laparotomy may be required.

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