Lower gastrointestinal bleeding

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Arbitrarily defined as overt intraluminal bleeding from a point below the ligament of Treitz. May present as haematochezia or clots. Massive upper GI haemorrhage may result in passage of blood and clots per rectally.

The approach is conservative initially with resuscitation with transfusion as necessary. If bleeding fails to stop, the approach is to identify a source and treat it with radiological or surgical intervention.

Investigation

Colonoscopy 
This may not identify a cause as blood may coat the bowel wall, obscuring adequate examination. Diverticular disease is easily demonstrated with colonoscopy. Even is a cause if not found, colonoscopy may identify a cut-off point, above which there is no blood. This helps target subsequent intervention, if required (e.g. segmental bowel resection instead of blind subtotal colectomy, or targetted mesenteric angiography of inferior mesenteric artery rather than superior mesenteric).
OGD 
To exclude an upper GI cause.
Mesenteric angiography 
Performed percutaneous with intravenous contrast dye. Requires brisk bleeding of at least 1-2ml/minutes.
CT showing pooling of contrast within the lumen of the bowel (right iliac fossa).
CT 'angiography' 
Intravenous contrast is administered and images are capture in the arterial and delayed phase. Maybe more sensitive than standard percutaneous angiography,[1][2][3] but not therapeutic. Pooling of the dye allows localisation of the bleeding, allowing a more selective approach with percutaneous angiography +/- embolisation. [4][5]

Causes

References

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