HEMATOCHEZIA & MELENA

Glen E. Hastings MD June 30, 2005 Definitions 1 : o Hematochezia, bright red or maroon colored blood in the stool is usually caused by lower GI bleeding although brisk UGI bleeding may also cause hematochezia. o Melena is black, tarry stool which is foul smelling because of the presence of partially digested blood products. Melena implies that the blood has been in the GI tract for at least 14 hours, & that usually indicates an upper GI source, but melena may also occur with bleeding from the small bowel or the right colon. Small bowel bleeding may present with either hematochezia or melena. III Clinical Evaluation: o Although the clinical history is frequently helpful in identifying the probable source of many upper GI bleeding episodes, it is less so when the bleeding source is the large or small bowel. In almost all cases the definitive diagnosis & frequently the management is most often by endoscopy. o The single most important part of the clinical examination is to carefully assess the vital signs, pulse, blood pressure, respiratory rate & core body temperature. The examining physician is advised to check these values personally as well as to evaluate the patient for postural pulse/blood pressure changes indicative of significant loss of blood volume. Such loss may not be apparent from the hematocrit or hemoglobin for 24 hours or more. o The principle goal of the clinical evaluation is not to nail the diagnosis of the bleeding source. It is rather to identify all probable complicating comorbidities in order to prevent acute complications. Far more patients with GI bleeding die of comorbidities than die from exsanguination. Table 1: Lower GI Causes of Hematochezia & Melena IV Etiologies1,2 : Sources % Diverticulosis 33% o Rectal Hemorrhoids & Anal Fissures are the Neoplasia (Polyps & Cancer) 19% most common causes of hematochezia. Usually Colitis: 18% symptoms are so mild that patients self medicate Inflammatory Bowel Disease 6% & do not seek medical attention. Bleeding from Ischemic Colitis 6% Infectious Colitis ulceration on a segment of prolapsed rectal 3% Radiation Colitis 3% mucosa is more likely to provoke medical Angiodysplasia 8% consultation. Anorectal conditions account for Anorectal Bleeding 4% about 8% in series of patients presenting with Miscellaneous 8% Post-polypectomy bleeding hematochezia. It is axiomatic that finding one of 3% Fecal Impaction <2% these obvious lesions does not preclude the Anastomotic bleeding <2% presence of a coexisting, more proximal & more Intussusception <1% serious lesion. Full colonoscopic evaluation is Aortocolonic fistula <1% indicated for all instances of hematochezia Undetermined 16% unless done previously within the past 2 years. These usually painful anorectal lesions rarely cause serious bleeding or require hospitalization. o Diverticulosis is the most common lower GI cause of hematochezia in adults & is progressively more likely with age. The usual onset is the abrupt painless presentation of bright red or maroon colored blood in the stool, which may be copious. Although melena may occasionally occur it is not characteristic, nor is occult bleeding. Eighty percent of bleeding episodes stop spontaneously & a purgative bowel prep followed by colonoscopic diagnosis & intervention is the usually effective first management. When bleeding is too brisk for proper visualization through the colonoscope, angiographic embolization of the bleeding vessel is reportedly effective in 93% of cases in which embolization is possible. Elective segmental bowel resection may be required in patients with repeated episodes of bleeding after endoscopic localization of the bleeding segment. II

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Neoplasia: Benign & malignant colon polyps as well as sessile & apple-core malignancies are increasingly prevalent in elderly patients but also occur as early as the 3rd or 4th decade in genetically predisposed patients. Although they are usually discovered by screening colonoscopy or present with mild intermittent or occult bleeding, they occasionally present with gross hemorrhage. Diagnosis & treatment are almost always preformed endoscopically with small early lesions & surgical intervention for more extensive disease. Angiodysplasia is probably the next most frequently seen lower GI cause of hematochezia. Two thirds of these patients are over 70 years of age, are more male than female & associated with the presence of aortic valvular stenosis. The bleeding site is identified by colonoscopy in 80 to 90% of cases & is generally amenable to local treatment. Bleeding recurs in about 20%. When colonoscopic electrocautery fails to control bleeding angiography & arterial embolization may be effective. In women with recurrent bleeding, transfusion requirements & bleeding episodes are reduced by administration of postmenopausal estrogen/progesterone therapy. In severe cases colonic resection may be required. Inflammatory Bowel Disease (IBD): The peak incidence of IBD is bimodal, the 1st peak occurring in the early 20s & the 2nd around age 70. Ulcerative colitis (UC) is much more likely to present with hematochezia than is Crohns disease (CD). Fifteen percent present with UC catastrophic onset; 1% with massive hematochezia. Most UC patients report a long history of tenesmus, cramping abdominal pain & sometimes intermittent mucoid stools prior to the first episode of bleeding. 95% of UC patients have rectal mucosal involvement. Crohns patients by contrast usually have a chronic history of recurrent colicky right lower quadrant abdominal pain, sometimes accompanied by fever, mimicking acute appendicitis. Although diarrhea is characteristic of acute flares of Crohns disease, gross bleeding is uncommon & only 1 to 2% bleed massively. Symptoms of bowel obstruction are more characteristic of Crohns disease & perirectal disease is much more frequent, affecting about . The gross appearance of the diffusely bright red inflamed colonic mucosa usually distinguishes UC from the skip areas, cobble-stone appearance, linear ulcerations & aphthus ulcers of Crohns disease. Full thickness mucosal inflammation with occasional granulomata are histologically characteristic of CD. Differentiation of UC from CD is impossible in 15% of cases. Treatment hinges on the clinical presentation. The incidence of late onset colon cancer in UC patients is related to the age of onset, the length of time since the original onset & the severity of the original episode, not to the subsequent level of disease activity. At 20 years it approaches 40% in patients who originally presented at age 15 or less who presented with pancolitis. Patients with early onset severe UC should therefore be offered annual colonoscopic surveillance beginning about 15 years after 3 disease onset . Ischemic Colitis is a very common cause of hematochezia in the elderly. It is not caused by large artery occlusion but by impaired mucosal perfusion in watershed areas between the distributions of major vascular territories. Hence, the most frequent bleeding sites are the splenic flexure, the descending or sigmoid colon. Presentation is usually with cramping left sided abdominal pain followed within 24 hours by hematochezia. Flat plate of the abdomen may show a classical thumbprints in the image of the colonic mucosa at the site of the involved segment. Most episodes resolve with supportive care. Surgical intervention is reserved for persistent hemorrhage & instances of septic clinical deterioration (fever, leukocytosis, etc). Infectious Colitis caused by Campylobacter jejuni, Shigella or Salmonella species, pathogenic E coli, Clostridium difficile or E. coli 0157:H7 may cause bloody diarrhea. Blood loss is rarely significant & the need for specific treatment is determined by stool culture & stool antigen assays. Post-Radiation Colitis 4 may occur immediately or may occur several years after radiation therapy for pelvic or colorectal cancer. A 3 year incidence of 14.3% was recently reported. Significant risk factors included age >60 & external beam radiation doses > 54Gy. Symptoms of proctitis & rectal bleeding may be troublesome & recurrent owing to recurring flairs of radiation induced vasculitis. Blood loss is rarely massive but chronic iron deficiency anemia is not. The condition tends to improve with time. Local enemas & cutaneous application of steroid or 5-ASA creams is conventionally given but treatment is often unsatisfactory.

Hematochezia: Page 3 of 4 Post-Polypectomy Bleeding1 occurs within 2 weeks following about 3% of endoscopic polypectomies. About 50% require transfusion. Most such patients have a concomitant bleeding risk like aspirin or warfarin therapy & > 95% are amenable to endoscopic treatment. o Unusual Causes: Fecal Impaction 5 , has been reported as a cause of clinically significant hematochezia, usually occurring as a result of manual disimpaction. Endoscopic or angiographic diagnosis & management have been reported. Rectal or Colonic Varices, usually caused by portal hypertension (termed portal colonopathy) may occasionally cause recurrent hematochezia. Rectal varices may sometimes be ligated & decompression of portal pressure with TIPS procedure or splenorenal shunt may be required. Solitary Ulcers of the Small Bowel, Colon or Rectum 6 usually associated with long term NSAID use may also cause hematochezia. Blood loss is rarely significant & specific treatment usually is generally unnecessary. Meckels Diverticulum of the Small Bowel is a frequent cause of obscure hematochezia accounting for about of such episodes occurring before age 15, typically producing painless currant-jelly stools. Although Meckels diverticula may cause obscure occult blood loss in adults, hematochezia is rare. Vascular ectasias, neoplasms (adenocarcinomata, leiomyomata, lymphomata, carcinoids or lipomas) Crohns disease, infections, ulcerations & various vasculidities of the small bowel are other more frequent causes. Intussusception of the small bowel or colon is an infrequent cause of hematochezia. When it occurs it is usually provoked by a structural intraluminal polyp or cancer. A sausageshaped abdominal mass may be palpable, especially in children. Barium enema sometimes resolves the intussusception in children. Surgery is usually required in adults. Aortoenteral Fistula have been described as a cause of hematochezia in adults. The diagnosis is made angiographically & the treatment is surgical. o Undetermined: In about 15% of cases in most series the source of bleeding remains unknown. Even those series in which extraordinary followup examinations were performed ended with 5% diagnostic failures. In elderly adults such cases are most likely related to small vascular ectasias that lack sufficient size for ready identification via the colonoscope. In young patients 99MTcpertechnetate scininigraphy may identify about 65% of Meckels diverticulae. Angiography may be helpful when bleeding is brisk & push enteroscopy of the small bowel using a pediatric colonoscope has produced a 20 to 40% improvement in diagnostic efficacy. Videocapsule enteroscopy is an experimental diagnostic technique with a 30 to 65% diagnostic yield but lacking therapeutic capacity & limited by inability to rotate the capsule in transit, so as to allow full visualization of the entire bowel lumen. Small bowel enteroclysis & intraoperative enteroscopy are reserved for those with severe persistent or recurrent hemorrhage because of the associated discomfort & morbidity. References: o
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Laine L. Gastrointestinal Bleeding. Ch. 37 in Harrisons Principles of Internal Medicine 16thEdition. Editors: Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL. McGraw-Hill NY,NY 2005 pages 235-8. Elta, GH, Approach to the patient with gross gastrointestinal hemorrhage. Ch 33 in Textbook of Gastroenterology 4 Edition. Editor: Yamada T. Lippincott, Williams & Wilkins Philadelphia PA 2002; pages 696-723.
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Ekbom A, Helmick C, Zack M, Adami HO. Ulcerative colitis and colorectal cancer. A population-based study.N Engl J Med. 1990;323(18):1228-33. Chen SW, Liang JA, Yang SN, et al. Radiation injury to intestine following hysterectomy and adjuvant radiotherapy for cervical cancer. Gynecol Oncol. 2004;95(1):208-14. Naderi MJ, Bookstein JJ. Rectal bleeding secondary to fecal disimpaction: angiographic diagnosis and treatment. Radiology. 1978;126(2):387-9. Byrne MF, McGuinness J, Smyth CM, et al. Nonsteroidal anti-inflammatory drug-induced diaphragms and ulceration in the colon. Eur J Gastroenterol Hepatol. 2002;14(11):1265-9.

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