GASTROENTEROLOGY CLINICS OF NORTH AMERICA Lower Gastrointestinal Bleeding—Management

A cute lower gastrointestinal bleeding (LGIB) is distinct clinically from upper gastrointestinal hemorrhage in epidemiology, prognosis, management, and outcome. LGIB encompasses a wide clinical spectrum ranging from trivial hematochezia to massive hemorrhage with shock, requiring emergency hospitalization. The spectrum of LGIB is broad. It may be acute or chronic, obvious or occult. This article focuses on managing patients with acute LGIB. Occult bleeding and obscure bleeding are discussed in articles by Lin and Rockey elsewhere in this issue. Evaluation of hemodynamic status and resuscitation are the cornerstones in the initial treatment of LGIB. They should take place concomitantly with the history and examination. Postural changes, chest pain, palpitations, syncope, pallor, dyspnea, and tachycardia suggest hemodynamic compromise [1]. An orthostatic decrease in systolic blood pressure of greater than 10 mmHg or an increase in heart rate of more than 10 beats/min indicates an acute loss of at least 15% of blood volume [1,2]. Two large caliber peripheral catheters or a central venous line should be placed immediately in patients with hemodynamic compromise. Initial laboratory studies should include a complete blood count, coagulation profile, type and cross-match, and electrolytes. The use of anticoagulants or nonsteroidal anti-inflammatory drugs (NSAIDs), the presence of liver disease, and serious comorbid medical conditions should be identified rapidly. Coagulopathy or thrombocytopenia should be corrected with fresh frozen plasma or platelet transfusions. In elderly patients or those with a history of cardiac disease, an electrocardiogram or cardiac enzymes should be obtained. The character and frequency of stool output should be noted, as it allows critical assessment of the severity of bleeding. Patients with brown or infrequent stools are unlikely to have brisk bleeding; those with frequent passage of red or maroon stool, however, may have aggressive ongoing bleeding [3].