Early Predictors of Severity in Acute Lower Intestinal Tract Bleeding

Abstract & Commentary

Synopsis: Initial clinical data can help predict high-risk patients with lower GI bleeding, including tachycardia, hypotension, syncope, and absence of abdominal tenderness.

Source: Strate L, et al. Arch Intern Med. 2003;163:838-843.

Clinicians often see patients with acute lower gastrointestinal (GI) hemorrhage. This presentation may be trivial or life threatening. Also, 20-30 per 100,000 persons are hospitalized with lower intestinal tract bleeding (LIB). Mortality may be high, particularly with sustained or recurrent hemorrhage. There are now data to suggest that colonoscopic intervention within 12 hours of admission may improve outcomes. It would be useful if appropriate high-risk patients could be selected for such intervention.

This study from the Brigham and Women’s Hospital in Boston reviewed all admissions for approximately 3 years up to July 1999. Exclusions included evidence of upper gastrointestinal (UGI) bleeding or a history of low-grade lower GI bleeding. Out of 2323 candidate admissions, 373 patients were ultimately identified as suitable for study. Fifty-seven percent of patients were female, mean age was 66, and mean initial hematocrit was 35%. Forty-one percent required transfusions, and 4% underwent surgery for bleeding control. The most common diagnoses were diverticular hemorrhage, ischemic colitis, post-polypectomy, and malignancy.

The risk factors identified were: blood pressure < 115 mm Hg, tachycardia, syncope, lack of abdominal tenderness on exam, gross blood on rectal exam or active bleeding within 4 hours of observation, aspirin use, and significant co-morbidities. Eighty-four percent of patients with more than 3 risk factors had severe LIB. Only 9% of patients with no risk factors experienced severe LIB.

Comment by Malcolm Robinson, MD, FACP, FACG

Simple clinical observation should allow stratification of risk in patients who present with LIB. It was interesting that lack of abdominal tenderness proved to be one of the risk factors, presumably because of the unlikelihood of tenderness in diverticular bleeding or bleeding from mucosal angiomas. Since colonoscopy may provide therapeutic options like epinephrine injection and thermal applications along with specific diagnosis in a great many patients with LIB, clinical stratification is clearly worthwhile.

Dr. Robinson is Medical Director, Oklahoma Foundation for Digestive Research and Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK.