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ORIGINAL ARTICLE
Year : 2017  |  Volume : 44  |  Issue : 3  |  Page : 148-151

Spectrum of the causes of lower gastrointestinal bleeding in geriatric patients in tertiary care hospital


1 Department of Medicine, Jawaharlal Nehru Medical College, KLE University's, Belagavi, Karnataka, India
2 Department of Gastroenterology, Jawaharlal Nehru Medical College, KLE University's, Belagavi, Karnataka, India

Date of Web Publication14-Feb-2018

Correspondence Address:



Santosh Hazare
Department of Gastroenterology, Jawaharlal Nehru Medical College, KLE University's, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_17_16

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  Abstract 

Context: Lower gastrointestinal bleeding (LGIB) patients in geriatric are the common indication of hospital admissions, with marked geographic variation in the frequency of different etiologies. Colonoscopy is considered as first-line diagnostic procedure of choice in evaluation of patients with bleeding per rectum. Aims: This study aims to determine spectrum of LGIB in our region using lower gastrointestinal (GI) endoscopy. Settings and Design: A retrospective study of 2-year period from August 2010 to July 2012, 2 years study in tertiary hospital. Subjects and Methods: The clinical data of patients admitted with per rectal bleeding were collected including age, sex, site of bleeding and the underlying cause. In all cases proctoscopy was done and colonoscopy after preparation and stabilization of the patients. Statistical Analysis Used: SPSS analysis. Results: During 2-year follow-up study, 45 patients were admitted with LGIB with mean age of 67.5 years, the bleeding site was in the colorectal causes found in 33 (73.3%) cases, while perianal in 6 (13.3%) of cases. Carcinoma was the most common cause. Conclusions: Bleeding per rectum is a common cause in geriatric patients admitted to Gastroenterology Department. Carcinoma is the most common cause of bleeding per rectum. There is wide geographic variation regarding the etiologies of LGIB. Lower GI endoscopy is very useful tool in evaluating patients with bleeding per rectum.

Keywords: Colonoscopy, colorectal carcinoma, lower gastrointestinal bleeding


How to cite this article:
Morkar DN, Hazare S. Spectrum of the causes of lower gastrointestinal bleeding in geriatric patients in tertiary care hospital. J Sci Soc 2017;44:148-51

How to cite this URL:
Morkar DN, Hazare S. Spectrum of the causes of lower gastrointestinal bleeding in geriatric patients in tertiary care hospital. J Sci Soc [serial online] 2017 [cited 2018 Sep 19];44:148-51. Available from: http://www.jscisociety.com/text.asp?2017/44/3/148/225499


  Introduction Top


Lower gastrointestinal bleeding (LGIB) is anatomically defined as bleeding beyond the ligament of Treitz. The term “LGIB” is therefore a misnomer, and a more appropriate term would be lower intestinal bleeding.[1] Acute LGIB is one of the most common gastrointestinal (GI) indications for hospital admission The exact incidence of LGIB is not known, but the annual incidence of hospitalization is approximately 20–27 episodes per 100,000 persons per year.[2] A 200-fold increase of LGIB is seen with advancing age from the third to ninth decades.[1] The incidence of LGIB increases with age and is more common in men than women. There are worldwide regional differences in the causes of LGIB. For example, in the countries of Western Europe and the United States diverticulosis coli is common and is also one of the most common causes of LGIB. In Asia, however, diverticulosis coli is not common and is a much less common cause of LGIB. The common causes of LGIB also vary, with diverticular bleeding accounting for 17%–56%; angiodysplasia, 3%–30%; hemorrhoids, 3%–28%; and polyps, 2%–30% in Western countries.[2] Previous evidence suggested that in our country, frequencies of different etiologies of LGIB are different from the West.[2] This study validated the previous findings. The epidemiology of LGIB in Western populations has been reported; however, there are scant Asian reports.

Aim of study

This study aims to determine spectrum of LGIB in our region using lower GI endoscopy.


  Subjects and Methods Top


This study was conducted at Dr. Prabhakar Kore's KLE Hospital and Medical Research Center Belgaum. Its retrospective study of 2-year period from August 2010 to July 2012. Forty-five patients were included in the study, who presented to gastroenterology outpatient department and medical and surgical wards. The clinical data of patients admitted with per rectal bleeding were collected including age, sex, site of bleeding, and the underlying cause. Patients with suspected upper GI source of bleeding; and acute infectious diarrhea were excluded from the study. All patients were subjected to fiberoptic colonoscopy after necessary preparation and findings were recorded. Biopsies taken from suspected lesions were clinically indicated. Diagnosis was based on colonoscopic. The following criteria have been suggested for identifying site of bleeding on colonoscopy:

  • Active colonic bleeding
  • Nonbleeding visible vessel
  • Adherent clot
  • Fresh blood localized to a colonic segment
  • Ulceration of diverticulum with fresh blood in adjoining area
  • Absence of fresh bleed in terminal ileum with fresh blood in the colon.



  Results Top


During the 2-year period of the study, 45 patients with LGIB were admitted to the Department of Gastroenterology, 39 males and 6 females [Graph 1], with a mean age of 67.5 years (range, 60–85 years) [Graph 2]. The range of the level of hemoglobin on admission was 6.3–12.4 g/dl. The site of bleeding was in the perianal region in six patients (13.3%) and in colorectal region in 33 patients (33.73%). Regarding the perianal causes, the total number is six patients, four males and two females. Among patients four patients had hemorrhoids, which is common cause of per rectal bleeding bleed, one patient had rectal ulcer and proctitis in one patient.



In our study, the most common symptom was intermittent per rectal bleeding in 32 (71.7%) [Table 1] patients and second most common symptom was pain abdomen found in 15 (33.33%) followed by frank bleeding 13 (28.8%), loose motion nine patients and loss of appetite in 4%, constipation was present in 1 (2%), and drug history (nonsteroidal anti-inflammatory drugs [NSAIDs]) in 1 (2%) [Graph 3].
Table 1: Presenting complaints

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Colorectal causes were found in 33 patients (73.3%), there were 29 males and 4 females, with a mean age of 67.5 years (range, 60–85 years). Among 33 cases, carcinoma colon was seven and carcinoma rectum was six. Carcinoma was the most common cause for PR bleed 12 (26.6%) cases [Table 2], [Figure 1] and [Figure 2]. Different varieties of colitis, including ulcerative colitis 8 (17.7%), and nonspecific colitis 9 (20%) were the causes of bleeding in patients. Diverticulosis was found in 2 (4.4%) cases and sigmoid polyp 1 (2.2%), diffuse ileitis in 1 (2.2%) cases for PR bleeding. In 6 (13.3%) patients, no cause for PR bleeding was found on colonoscopy, one patient had altered blood on colonoscopy anemia was present in 22 (48.8%) patients [Graph 4]. Among 22 patients, two cases had severe anemia. One patient had carcinoma colon and one patient was ulcerative colitis. Three cases had moderate anemia and 23 (25.5%) had mild anemia.
Table 2: Causes of lower gastrointestinal bleed in study group

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Figure 1: Lower gastrointestinal bleed

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Figure 2: Lower gastrointestinal bleed(active bleeding)

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  Discussion Top


Comorbid LGBI is common geriatric problem. Most patients who have LGBI have favorable outcome despite advance age and other comorbid conditions. The clinical course of LGIB can vary widely in the elderly patients from occult bleeding to massive life-threatening hemorrhage and death. Common presenting symptoms of LGIB may not be evident in the elderly. For example, in the elderly patients who are taking NSAIDs, abdominal pain may not be present. Most common presentation in our study was intermittent per rectal bleeding followed by pain abdomen. Which was similar to other studies.[2] Most of the patients presented with bleeding per rectum are worried and anxious about the malignancy until a diagnosis is reached. The bleeding site and cause are strongly related to the age of the patient. It is well known that diverticulosis and arteriovenous malformation have been found to be more common in the elderly,[3] while perianal causes such as hemorrhoids and anal fissures occur in the younger age group.[4] The risk of malignancy in patients with per rectal bleeding is also increasing with age.

In this study, patients presenting with LGIB, carcinomas were the most common cause. The second most common cause was ulcerative colitis and nonspecific colitis. A study done by, Goenka et al.[5] in India [Table 3], showed ulcerative colitis being the most common followed by polyps, colonic carcinoma, and colonic tuberculosis, which is similar to other study from Pakistan and China, where ulcerative colitis and malignancies are the leading colonic pathologies responsible for LGIB, but they have not specified age of the population, while diverticular disease is not common in such populations. Hemorrhoids were also found to be the most common cause of bleeding per rectum in a Jordanian review of 701 patients.[6] There is a general agreement in most of series that, the overall most common cause of rectal bleeding is hemorrhoids. One of the studies conducted by Akhtar USA, mos common cause was hemorrhoids (60) patient but in our study hemorrhoids was forth cause (4) 8.80%. Bleeding from colon and rectum represents 26% of our cases admitted with LGIB, with mean age of 68 years. In another series from Singapore, colorectal causes made Wup 12% of cases admitted to the hospital with bleeding per rectum, with a mean age of 70 years.[7] Regarding the colorectal causes of bleeding per rectum, most of the studies have been done in the Western countries demonstrate a different etiological pattern as compared to other studies from different populations of developing countries [Table 4].
Table 3: Indian study showing causes of perirectal bleed according to site

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Table 4: Comparison of lower gastrointestinal bleeding by location in different studies

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In our study, the most common cause of bleeding per rectum was a colorectal carcinoma, followed by colitis, hemorrhoids and then diverticulosis and polyps with the same incidence. These results are different from the results of many series that reviewed in the literature. In Western population, diverticular disease found to Al-satil Journal 13 be the most common cause of rectal bleeding. Zuckerman and Prakash found diverticulosis being the most common cause in the USA, followed by carcinoma and polyps, and then colitis and ulcers [Table 3]. Which is compatible with other studies from the Western countries in which diverticulosis is a common disease, and found to be the most common cause of LGIB.[1],[2],[3],[8] An important implication of finding abundant cases of ulcerative colitis and colorectal carcinoma is the identification of patients having increased risk of carcinoma. Since patients with inflammatory bowel disease are at an increased risk of developing colorectal carcinoma, it is possible that most cases of colorectal carcinoma may have developed in the pretext of ulcerative colitis. Hence, in our series, we found that colorectal carcinoma is the most common cause of bleeding per rectum, which is different from the West and the East. Colonoscopy can be used as the initial diagnostic modality to find out cause for per rectal bleeding.[9] The most obvious advantages of colonoscopy are its ability to establish a diagnosis by direct visualization of the mucosa, to identify any bleeding lesion, to take a biopsy, and the ability of some therapeutic interventions. The use of radionuclide scanning and angiography was uncommon and may be useful in evaluating bleeding in patients with normal colonoscopy.


  Conclusions Top


Lower GI hemorrhage is a common cause of admission to the Gastroenterology and Surgical Department. Carcinomas most common and second most common cause colitis are causes for bleeding per rectum among our study and Asian. The most common cause of colorectal bleeding in our patients was carcinomas, while in Western countries, diverticulosis is the commonest cause, and ulcerative colitis is the most common cause in some Eastern countries. Colonoscopy is the diagnostic procedure of choice both of its accuracy in the localization of the etiology of bleeding and its therapeutic advantage.

Acknowledgment

I would like to thank all who supported me, including my family, friends and postgraduate students for their sincere time and support.

Financial support and sponsorship

This study was supported by SPSS.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Strate LL. Lower GI bleeding: Epidemiology and diagnosis. Gastroenterol Clin North Am 2005;34:643-64.  Back to cited text no. 1
    
2.
Tariq SH, Mekhjian G. Gastrointestinal bleeding in older adults. Clin Geriatr Med 2007;23:769-84, vi.  Back to cited text no. 2
    
3.
Edelman DA, Sugawa C. Lower gastrointestinal bleeding: A review. Surg Endosc 2007;21:514-20.  Back to cited text no. 3
    
4.
DeMarkles MP, Murphy JR. Acute lower gastrointestinal bleeding. Med Clin North Am 1993;77:1085-100.  Back to cited text no. 4
    
5.
Goenka MK, Kochhar R, Mehta SK. Spectrum of lower gastrointestinal hemorrhage: An endoscopic study of 166 patients. Indian J Gastroenterol 1993;12:129-31.  Back to cited text no. 5
    
6.
Shennat MM, Tarawneh MM, Pattern of colonic disease in lower gastrointestinal bleeding in jordanian patients:a prospective colonoscopic study Dis Colon Rectum 1997:40:208-14.  Back to cited text no. 6
    
7.
Tan BK, Tsong CB Nyam DC HOYH, management of acute bleeding per rectum. Asian J Sung 2004;27:32-8.  Back to cited text no. 7
    
8.
Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: Etiology, therapy, and outcomes. Gastrointest Endosc 1999;49:228-38.  Back to cited text no. 8
    
9.
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;20:73-6.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
Introduction
Subjects and Methods
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