Comprehensive review on the current management of lower-gut bleed

Traditionally, lower gastrointestinal bleeding (LGIB) was defined as a bleed that originates from the gastrointestinal (GI) tract distal to the ligament of Treitz. In recent literature, LGIB is defined as bleeding from the colon or anorectum. The global incidence of LGIB ranges from 20.5 to 87.0 per 100,000 person-years with an estimated mortality rate of 2.5% to 3.9% and rebleeding rates after one year ranges from 13% to 19%. Diverticular bleeding is the most common cause for LGIB in west, while colitis and hemorrhoids were the leading causes for LGIB in studies conducted across India. Colonoscopy has both diagnostic and therapeutic roles in patients with acute LGIB. It should be considered the initial diagnostic modality in all hemodynamically stable patients presenting with acute LGIB. The initial assessment should include a focused history, physical examination, laboratory evaluation that hints towards the site of bleeding and possible etiology. Patients with hemodynamic instability should be resuscitated with intra-venous crystalloids with the goal of normalization of heart rate and blood pressure before conducting any diagnostic or therapeutic procedure. It should be considered the initial diagnostic modality in all hemodynamically stable patients presenting with acute LGIB. Various endoscopic hemostatic measures such as adrenaline injection, clip application, thermal coagulation and/or band ligation can be used to control bleeding during colonoscopy. Computed tomography angiography (CTA) plays an important role in the diagnosis and management of acute LGIB especially in hemodynamically unstable patients and when colonoscopy fails to achieve hemostasis. Management of GI bleeding in patients who are on anticoagulants and antiplatelets and also those who have undergone cardiac stenting within one year should involve a multi-disciplinary approach.