CAUSES OF LOWER GASTROINTESTINAL BLEEDING ON COLONOSCOPY
AbstractBackground: Rectal bleeding can refer to any blood that passes from the anus, although rectal bleeding is usually assumed to refer to bleeding from lower colon or rectum, which means bleeding from a place distal to ligament of Treitz. The estimated annual incidence rate is around 20.5 patients per 100,000; however, in individuals in the third to the ninth decades, the incidence rate of lower GI bleed increases more than 200-fold, and mortality due to lower GI bleed as 11%. Many modalities and investigations have been studied and proctosigmoidoscopy followed by colonoscopy is the investigation of choice for diagnosis and treatment for these patients. Previous studies suggested that in our country, frequencies of different aetiologies of lower GI bleed are different from the rest of the world, especially the west. This study validated the previous findings. The Objective of this study was to determine the frequency of different causes of rectal bleeding in patients at Ayub Teaching Hospital, Abbottabad. Methods: One hundred and nine patients with evidence of rectal bleed, without gender discrimination were selected by non-probability convenient sampling from the out-patient department and general medical wards. Patients with suspected upper GI source of bleeding; acute infectious bloody diarrhoea and any coagulopathy were excluded from the study. All patients were subjected to fibre-optic colonoscopy after preparation of the gut and findings were recorded. Where necessary, biopsy samples were also taken. Diagnosis was based on colonoscopic findings. Results: A total of 109 patients (57 males and 52 females) with mean age 35.81+19.18 yrs were part of the study. Colonoscopy showed abnormal findings in 91 (83.5%) patients. The commonest diagnosis was hemorrhoids, which was found in 23 (21.1%) patients. It was followed by inflammatory bowel disease (IBD) in 20 (18.3%) patients, solitary rectal ulcer in 9 (8.3%) patients and polyps in 9 (8.3%) patients. Other less frequent findings were non-specific inflammation and fungating growths in rectum. Conclusion: Colonoscopy can provide a visual diagnosis (e.g. ulceration, polyps) and grants the opportunity for biopsy or removal of suspected colorectal cancer lesions. Colonoscopy has a high diagnostic yield and is now the investigation of choice in patients presenting with bleeding per rectum. Hemorrhoids was the leading cause of bleeding per rectum in this study, followed by evidence of IBD while infrequent findings of polyps and diverticuli indicate that these are uncommon in this region.Key Words: Colonoscopy , Gastrointestinal Haemorrhage, HemorrhoidsBackground: Bleeding from anus is usually referred as rectal bleeding but actually rectal bleeding is defined as bleeding from lower colon or rectum, which means bleeding from a place distal to ligament of Treitz. This study was conducted to determine the frequency of different causes of rectal bleeding in patients at Ayub Teaching Hospital, Abbottabad. Methods: One hundred and seventy-five patients with evidence of rectal bleed, without gender discrimination were selected by non-probability convenient sampling from the out-patient department and general medical wards. Patients with suspected upper GI source of bleeding; acute infectious bloody diarrhoea and any coagulopathy were excluded from the study. All patients were subjected to fibre optic colonoscopy after preparation of the gut and findings were recorded. Where necessary, biopsy samples were also taken. Diagnosis was based on colonoscopic findings. Results: A total of 175 patients (92 males and 83 females) with mean age 35.81±9.18 years were part of the study. Colonoscopy showed abnormal findings in 150 (85.7%) patients. The commonest diagnosis was haemorrhoids, which was found in 39 (22.3%) patients. It was followed by inflammatory bowel disease (IBD) in 30 (17.1%) patients, solitary rectal ulcer in 13 (7.4%) patients and polyps in 25 (14.3%) patients. Other less frequent findings were non-specific inflammation and fungating growths in rectum. Conclusion: Haemorrhoids was the leading cause of bleeding per rectum in this study, followed by evidence of IBD while infrequent findings of polyps and diverticuli indicate that these are uncommon in this region.Keywords: Colonoscopy; Gastrointestinal Haemorrhage; Haemorrhoids
Cutler JA, Mendeloff AI. Upper gastrointestinal bleeding. Nature and magnitude of the problem in the U.S. Dig Dis Sci 1981;26(Suppl 7):S90–6.
Hilsden RJ, Shaffer EA. Management of gastrointestinal hemorrhage. Can Fam Physician 1995;41:1931–41.
Kim BS, Li BT, Engel A, Samra JS, Clarke S, Norton ID, et al. Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World J Gastrointest Pathophysiol 2014;5(4):467–78.
Wolfson AB, Harwood-Nuss A, editors. Harwood-Nuss’ clinical practice of emergency medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
Lewis JD, Brown A, Locallo AR, Shwartz JS. Initial evaluation of rectal bleeding in young persons: a cost effectiveness analysis. Ann Intern Med 2002;136(2):99–110.
Hreinsson JP, Kalaitzakis E, Gudmundsson S, Björnsson ES. Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013;48(4):439–47.
Aoki T, Nagata N, Niikura R, Shimbo T, Tanaka S, Sekine K, et al. Recurrence and Mortality Among Patients Hospitalized for Acute Lower Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2014;13(3):488–94.
Dutta G, Panda M. An uncommon cause of lower gastrointestinal bleeding: a case report. Cases J 2008;1(1):235.
Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice parameters committee. Am J Gastroenterol 1998;93(8):1202–8.
Moayyedi P, Ford A. Recent developments in gastroenterology. BMJ 2002;325(7377):1399–402.
Gayer C, Chino A, Lucas C, Tokioka S, Yamasaki T, Edelman DA, et al. Acute lower gastrointestinal bleeding in 1,112 patients admitted to an urban emergency medical center. Surgery 2009;146(4):600–7.
Nasir SA, Anjum AH, Arshad M, Siraj MI, Tareen MA. Diagnostic colonoscopy. Pak J Gastroenterol 1990;4:43–5.
Zia N, Hussain T, Salamat A, Mirza S, Hassan F, Waqar A. Diagnostic evaluation of patients presenting with bleeding per rectum by colonoscopy. J Ayub Med Coll Abbottabad 2008;20(1):73–6.
Hafeez Bhatt AB, Quraishy MS. Flexible sigmoidoscopic findings in patients with fresh rectal bleeding. J Coll Physicians Surg Pak 2011;21(9):577–8.
Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg 1998;64(8):723–8.
Davies, RJ. Haemorrhoids. Clin Evid 2006;(15):711–24.
Lorenzo-Rivero S. Hemorrhoids: diagnosis and current management. Am Surg 2009;75(8):635–42.
Singer M. Hemorrholds. In: Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos MJ, Nasseri Y, editors. The ASCRS textbook of colon and rectal surgery. 2nd ed. Springer Science & Business Media; 2011. p.175–202.
Hanauer SB. Inflammatory bowel disease. N Engl J Med 1996;334(13):841–8.
Loftus EV Jr. Clinical epidemiology of inflammatory bowel disease: Incidence, prevalence, and environmental influences. Gastroenterology 2004;126(6):1504–17.
Giacosa A, Frascio F, Munizzi F. Epidemiology of colorectal polyps. Tech Coloproctol 2004;8(Suppl 2):S243–7.
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