Definition and Etiology
• Bleeding under the ligament of Treitz (jejunum, ileum, colon and rectum) is defined as lower GI bleeding.
• The most common causes of lower GI bleeding are anal hemorrhoids and fissures. However, these bleedings are usually mild. The most common cause of massive lower GI bleeding is diverticular disease.
• Bleeding under the ligament of Treitz (jejunum, ileum, colon and rectum) is defined as lower GI bleeding.
• The most common causes of lower GI bleeding are anal hemorrhoids and fissures. However, these bleedings are usually mild. The most common cause of massive lower GI bleeding is diverticular disease.
• Hemorrhoids and anal fissure (most common - mild)
• Diverticular disease (most commonly severe bleeding)
• Angiodysplasia (> 70 years of age, most common severe bleeding)
• Colon polyps, colon cancers
• Inflammatory bowel diseases
• Rectal ulcer
• Ischemic colitis
• Small intestine diseases
Clinic
• Melena: It is usually a sign of upper GI bleeding, but it can also be seen in lower GI bleedings that are up to the proximal parts of the colon and that are slow.
• Hematochezia: It is the most important finding of lower GI bleeding. As the bleeding focus approaches the rectum and anus, it changes to this red-colored image of fresh blood, darkening towards the proximal part of the colon, to a cherry bruise color.
Diagnosis
• If the patient has a suspicion of upper GI bleeding, upper endoscopy should be performed first.
• Colonoscopy is the most important and primary diagnostic method in lower GI bleeding. However, colonoscopy may not be technically possible during active bleeding. In this case, angiography and scintigraphy are helpful in diagnosis.
• Angiography can also be used for therapeutic purposes to stop bleeding.
• CT angiography is recommended for localization of the bleeding site before angiography and is superior to scintigraphy.
Treatment
Lower GI bleeding is usually not massive.
Following the emergency approach steps, the patient is followed up and the etiology is investigated by colonoscopy under elective conditions. Endoscopic treatment methods are applied to vascular lesions detected in colonoscopy.
In patients with ongoing massive bleeding, angiography is performed and radiological treatment methods are applied.
Surgical treatment is applied in severe bleeding that cannot be controlled.
Focal uncertain GI bleeding
• GI bleeding in which the bleeding focus cannot be determined despite upper and lower endoscopy is called obscure bleeding.
• The most common cause of focal uncertain bleeding is small intestinal bleeding.
• For the evaluation of these patients, angiography is recommended during active bleeding, and capsule endoscopy is primarily recommended if there is no active bleeding.
• Advanced research and imaging methods such as enteroscopy techniques (double-balloon, single-balloon, spiral), CT enterography, MR enterography, angiography are applied in patients who cannot find a bleeding focus.
• Intraoperative endoscopy is performed in patients whose focus cannot be detected despite all investigations and bleeding continues.