|Year : 2018 | Volume
| Issue : 2 | Page : 300-302
Etiological profile of patients with lower gastrointestinal bleeding: A 1-year cross-sectional study
Santosh Hajare, Ravindra Kantamaneni
Department of Medicine, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
|Date of Web Publication||27-Dec-2018|
Dr. Santosh Hajare
Department of Medicine, Jawaharlal Nehru Medical College, Nehru Nagar, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
The objective of the study was to determine the etiological profile of patients presenting with lower gastrointestinal bleeding (LGIB). This was a cross-sectional study including fifty patients with LGIB enrolled between January 2015 and December 2015. Patients aged 18 years and more with LGIB were included in the study. Endoscopy was performed within 24 h of admission, detailed history was recorded, and the frequency was calculated using Microsoft excel spreadsheet. The categorical data were expressed in terms of rates, ratios, and percentages and continuous data were expressed as mean ± standard deviation. The mean age of patients was 43.82 ± 17.96 years. Higher incidence of GI bleeding was observed in the age group of 18–30 years (34%). Hematochezia (80%) was the most common clinical feature, followed by constipation (78%). Hemorrhoids (48%) followed by ulcerative colitis (24%) were the most important colonoscopic findings determining the etiological factors. Based on the etiological profile, internal hemorrhoids and ulcerative colitis were the leading causes with a male preponderance in both the etiological factors. Men had a history of smoking and alcohol consumption implying that tobacco and other abuses increase the risk of LGIB.
Keywords: Colonoscopy, etiology, lower gastrointestinal bleeding
|How to cite this article:|
Hajare S, Kantamaneni R. Etiological profile of patients with lower gastrointestinal bleeding: A 1-year cross-sectional study. Arch Med Health Sci 2018;6:300-2
|How to cite this URL:|
Hajare S, Kantamaneni R. Etiological profile of patients with lower gastrointestinal bleeding: A 1-year cross-sectional study. Arch Med Health Sci [serial online] 2018 [cited 2019 May 26];6:300-2. Available from: http://www.amhsjournal.org/text.asp?2018/6/2/300/248664
| Introduction|| |
The surface area of gastrointestinal (GI) tract is highly vascularized and thus any acute injury of the GI tract may result in GI bleeding. GI bleeding in any age group requires immediate intervention. Lower GI bleeding (LGIB) is defined as the blood loss of recent onset originating from the distal site of ligament of Treitz, at the duodenojejunal junction. Approximately 20% of all cases of GI bleeding account for LGIB as compared to upper GI bleeding. Compared to the West, the Indian milieu displays increased incidence in younger patients with a rebleed rate of 4%.
LGIB is classified as acute LGIB and chronic LGIB. Acute LGIB refers to new onset bleeding (<3 days) resulting in vital sign instability, anemia, and/or blood transfusion. Chronic LGIB is explained as the flow of blood through the rectum for a longer period of time, usually indicating slow or intermittent blood loss. Furthermore, LGIB can be divided into clinically overt GI bleeding (hematochezia and melena) and occult bleeding determined by iron deficiency of unknown cause.
The etiological factors of LGIB vary depending on the environmental conditions, way of living, dietary habits, history of smoking and drug abuse, age, etc., However, a contrast in the etiological factors is observed in the Indian scenario with a 30% incidence of nonspecific ulcers followed by enteric ulcers (15%), neoplasm (6%), tubercular ulcers (6%), angiodysplasia (6%), amoebic ulcers (6%), and others (31%). In the Western countries, colonic diverticulum is considered to be the most common cause of LGIB. Other common causes include angiodysplasia, colitis, carcinoma, intestinal bleeding, and postpolypectomy bleeding.
The detection of the source of bleeding continues to be challenging along with 25% risk of rebleeding. In patients with stern hematochezia, defined as passage of fresh blood per anus, usually in or with stools with a drop in the hemoglobin level (at least 2 g/dl) and/or requirement of transfusion of at least 2 units of packed red blood cells, urgent intervention is required to prevent further bleeding and related complications. Colonoscopy is the most common diagnostic approach to detect the source of bleeding.
Most of the studies have reported etiology of LGIB in Western populations. A lot of studies are available about the etiology and time trends of upper GI bleeding; however, the data about the incidence of LGIB in India are limited. Furthermore, the etiological profile of LGIB is not specified. Hence, the present study was conducted to determine the etiological profile of the patients presenting with LGIB.
| Materials and Methods|| |
Cross-sectional study performed for 1 year from January 2015 to December 2015.
Sample and data collection
A total of 50 patients admitted to the Department of Medicine and Gastroenterology were enrolled in the study. Patients aged 18 years and more with LGIB – all patients with first admission with hematochezia – were included in the study. Patients incapable of undergoing lower GI video endoscopy and those unwilling to consent for colonoscopy were excluded from the study [Figure 1]. Before the commencement of study, ethical clearance was obtained from the Institutional Ethical Committee. After explaining the purpose of the study, a written informed consent was obtained from all the participants before data collection. The data were recorded in a predesigned and pretested proforma.
|Figure 1: Data representing the inclusion and exclusion of patients in the study|
Click here to view
The samples were examined for LGIB using forward-viewing curved linear array (Olympus EUS Solutions, USA). Endoscopy – intended colonoscopy – was performed within 24 h of admission, based on the nature of the urgency of the patient's condition. Prep was administered to the patients, which consisted of magnesium sulfate, sodium sulfate, and potassium sulfate. Subjects were advised to take prep on the night before colonoscopy; next day early morning, colonoscopy was done.
The available data were coded and entered into Microsoft Excel spreadsheet for further analysis.
| Results and Discussion|| |
LGIB is a widespread clinical condition related with considerable morbidity and mortality. The severity spectrum varies from mild per rectal bleeding to life-threatening massive hemorrhage. The baseline characteristics of patients are depicted in [Table 1]. LGIB is more commonly seen in men. In our study, male predominance (62%) was observed, which is in accordance with a study conducted by Peura et al. Tobacco abuse, alcohol consumption, low fiber diet, and reduced fluid intake increase transit time in the colon and retain fecal wastage enhancing the risk of LGIB in men. Elderly patients (80 years) have >200-fold increase in the incidence of LGIB as compared to younger patients. The mean age of patients with LGIB ranges between 63 and 77 years. In contrast to these observations, in the current study, LGIB afflicted the middle-aged population in their third and fourth decade of life (mean age of 43.82 ± 17.96 years). Maximum patients affected were in the age group of 18–30 years (34%) and the least affected were the elderly population aged between 71 and 80 years (2%) and age group of 81–90 years (4%).
|Table 1: Baseline demographic characteristics of patients with lower gastrointestinal bleeding|
Click here to view
Clinically, the most common presentation of LGIB is hematochezia, though melena, hemodynamic instability, anemia, and abdominal pain can also be seen. A study by Dar et al. observed hematochezia (63.3%) as the most common presentation followed by bloody diarrhea (17%), anorectal bleeding (12.33%), and melena (7%). Similarly, in the present study, majority of the patients presented with hematochezia (80%) as the common clinical feature followed by constipation (76%).
The etiology and epidemiology of LGIB depend on the age, lifestyle, dietary habits, smoking habit, history of drug intake, and longevity of the population. In the present study, 90% of the patients reported a history of a mixed diet, and history of smoking and alcohol consumption was observed in 20% and 18% of the patients, respectively. Diabetes mellitus (12%) has been the most frequently observed past medical history followed by diabetes mellitus with hypertension (4%).
In a study conducted by Alruzug et al., hemorrhoids (38.5%), diverticulosis (12.1%), and malignant neoplasm (9.9%) were reported to be the most common colonoscopic findings of LGIB. Similarly, in the present study, hemorrhoids (48%) followed by ulcerative colitis (24%) and carcinoma of the colon (10%) were the important colonoscopic findings [Table 2].
The spectrum of sources appears to be changing over time. In the early 20th century, neoplasia was reported as the predominant cause of LGIB and diverticular bleeding was presumably rare. Currently, diverticular bleeding is the leading source of LGIB. Even though increased hospitalizations have been observed in the elderly with the most common causes being diverticulosis, ischemic colitis, vascular malformation, and neoplasms, the etiological spectrum changes in the young and middle-aged groups. Patients in these age groups tend to bleed from hemorrhoids, vascular malformations, and rectal ulcers., These findings are in aggregation with the current study in which internal hemorrhoid (48%) was the most common cause followed by ulcerative colitis (24%).
| Conclusion|| |
Internal hemorrhoids and ulcerative colitis were the major causes of LGIB. The study findings could direct further research toward the analysis of correlation of the etiological factors with other clinical parameters to potentially improve the outcomes in the patients. In future, research is required on larger sample size of patients with LGIB to understand the etiology of the disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zahmatkeshan M, Fallahzadeh E, Najib K, Geramizadeh B, Haghighat M, Imanieh MH. Etiology of lower gastrointestinal bleeding in children: a single center experience from Southern Iran. Middle East J Dig Dis 2012;4:216-23.
Dar IA, Dar WR, Khan MA, Kasana BA, Sofi NU, Hussain M, et al
. Etiology, clinical presentation, diagnosis and management of lower gastrointestinal bleed in a tertiary care hospital in India: A retro-prospective study. J Dig Endosc 2015;6:101. [Full text]
ASGE Standards of Practice Committee, Pasha SF, Shergill A, Acosta RD, Chandrasekhara V, Chathadi KV, et al.
The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014;79:875-85.
Khandelwal C. Lower gastrointestinal bleeding. Indian J Surg 2003;65:151-5.
Loffeld RJ, van der Putten AB. Newly developing diverticular disease of the colon in patients undergoing repeated endoscopic evaluation. J Clin Gastroenterol 2002;35:205-6.
Vernava AM 3rd
, Moore BA, Longo WE, Johnson FE. Lower gastrointestinal bleeding. Dis Colon Rectum 1997;40:846-58.
Shrestha UK. Etiological profile, gender difference and age group patterns of 415 patients presenting with lower gastrointestinal bleeding in the western region of Nepal. J Adv Internal Med 2015;3:52-5.
Peura DA, Lanza FL, Gostout CJ, Foutch PG. The American College of GastroenterologyBleeding Registry: Preliminary findings. Am J Gastroenterol 1997;92:924-8.
Alruzug IM, Aldarsouny TA, Semaan T, AlMustafa A. Lower gastrointestinal bleeding in Saudi patients: A retrospective longitudinal study. J Gastrointest Digestive Sys 2016;6:410.
Strate LL. Lower GI bleeding: Epidemiology and diagnosis. Gastroenterol Clin North Am 2005;34:643-64.
Barnert J, Messmann H. Management of lower gastrointestinal tract bleeding. Best Pract Res Clin Gastroenterol 2008;22:295-312.
[Table 1], [Table 2]