Massive Lower Gastrointestinal Hemorrhage in Crohn's Disease

Acute lower gastrointestinal bleeding is an uncommon but potentially life-threatening complication of Crohn's disease. Because of the relative infrequency of severe bleeding due to CD, reports of larger numbers of cases are few, and the medical literature provides insufficient information to direct management. Nevertheless, certain clear guidelines can be offered once other causes for GI blood loss have been excluded and the diagnosis of a Crohn's-related bleed is likely. While the initial episode may abate spontaneously, the primary treatment is determined by the severity and persistence of bleeding as well as the risk for recurrence. Localization of the site of bleeding is essential whether endoscopic therapy, surgery, or medical management is attempted. Endoscopic evaluation is preferable, if feasible, as it will provide a broader assessment of extent of disease as well as having a reasonable likelihood of identifying the site of bleeding with possible therapeutic intervention. An angiogram can be a useful alternative, but therapeutic intervention with embolization should be avoided because of the risk for intestinal infarction. Surgery remains the standard of care for persistent severe acute bleeds. If the acute bleeding ceases, an interval to attempt pharmacologic therapy may be available, permitting treatment of the underlying Crohn's disease. Newer therapies such as infliximab, which may produce relatively rapid mucosal healing, may be beneficial; while they offer hopeful treatment alternatives, they have not been demonstrated to be of use for these cases.