Case Of Lower Gastrointestinal Bleeding Research Articles

A Rare Cause of Lower Gastrointestinal Bleeding: Rectal Dieulafoy’s Lesion

Dieulafoy’s lesion is rare cause of life-threatening gastrointestinal bleeding. Mortality is high if not early diagnosed and treated properly. Thus, it must be excluded and treated in patients with GIB as fast as possible. These lesions are usually observed in upper gastrointestinal system and mostly in the stomach. It is very rare in rectum. Here we report a rare case of lower gastrointestinal bleeding caused by rectal Dieulafoy’s lesion.

S2579 Colonic Varices: What Are the Therapeutic Options?

Introduction: Colonic varices are a rare case of lower gastrointestinal bleeding (LGIB) with an incidence of 0.07%. The most common sites of colonic varices are the rectum and cecum. Colonic varices are diagnosed on colonoscopy, mesenteric angiography, or computed tomography (CT) scans. Currently, there are no standardized treatments for treatment of colonic varices due to the heterogeneity in localization and vascular anatomy. We present a case of LGIB due to an ascending colon varix. Case Description/Methods: A 38 year-old-man with a history of decompensated alcoholic cirrhosis complicated by esophageal and gastric variceal bleed requiring balloon-occluded retrograde transvenous obliteration one month ago was transferred from an outside hospital (OSH) for liver transplant evaluation and hematochezia. He underwent a colonoscopy at the OSH which showed an ascending colon varix with white nipple sign. His vital signs were normal. His physical exam was benign except for scleral icterus with spider angiomas on his chest. His labs were pertinent for a hemoglobin of 8.0, hematocrit 24, platelet 50,000, alanine aminotransferase 50, total bilirubin 3.0, and international normalized ratio 2.0. The patient was treated with octreotide infusion and antibiotics for spontaneous bacterial peritonitis prophylaxis. A CT three phase abdominal imaging was revealed significant perisplenic and ascending colon varices with smaller varices supplying the descending colon. The case was reviewed with interventional radiology and hepatology and the patient underwent transjugular intrahepatic portosystemic shunt (TIPS) placement with coil and plug embolization of the splenic varix and gonadal varix feeding into the ascending colon varix. The patient did not have any further episodes of hematochezia and his hemoglobin stabilized. A few days later, the patient underwent an orthotic liver transplant. His post-operative clinical course was uncomplicated. Discussion: This is a rare case of a colonic varix resulting in a clinically significant LGIB. There is no standardization of therapy for ectopic varices due to the heterogeneity in vascular anatomy. Therapeutic options include endoscopic variceal band ligation, cyanoacrylate injections, surgery, TIPS and coil embolization. This case highlights the importance of a multi-disciplinary approach with gastroenterologists, hepatologist, interventional radiologists, and surgeons for the treatment of colonic varices.

Minimal invasive management of proximal small bowel bleeding: A case report and reviewing the evidences

Objective: Gastrointestinal bleeding is one of the surgical emergencies that is routinely visited in emergency departments. Although most of these patients are managed with endoscopic modalities, some of them are managed with surgical interventions. Most of emergency surgical interventions are done via laparotomy. With evolution in minimal invasive surgery, the role of laparoscopic surgeries in emergency settings is on a rise. Case Presentation: In this report we describe a case of lower gastrointestinal bleeding that was presented with melena and during workups no bleeding lesion was detected in colon, stomach or duodenum. Further investigations revealed bleeding of proximal jejunum mass that was resected with the laparoscopic approach which is rarely used in the emergency management of patients with gastrointestinal bleedings. Also, resection and anastomosis of proximal jejunal loop was challenging in this case. Conclusion: This report is intended to describe the feasibility of laparoscopy in proximal small bowel lesion resection in emergency settings as well as the role of computed tomography (CT) angiography in detecting the source of obscure gastrointestinal bleeding.

Appendiceal bleeding in an elderly male: a case report and a review of the literature

BackgroundThe prevalence of acute lower gastrointestinal bleeding has been increased including colonic diverticulitis and angioplasty. However, appendiceal bleeding is extremely rare.Case presentationWe present a case of lower gastrointestinal bleeding from the appendix in an elderly male who presented with melena. Appendiceal bleeding was diagnosed using lower gastrointestinal endoscopy, and laparoscopic appendectomy was performed. The patient did not have melena postoperatively, and was discharged 6 days after the surgery.ConclusionIt is important to distinguish appendiceal bleeding from lower gastrointestinal bleeding and to treat it as soon as possible with less invasiveness.

591 Trend Analysis of Lower Gastrointestinal Bleeding 2002-2017: A Population-Based Study

INTRODUCTION: Lower Gastrointestinal Bleeding (LGIB) is defined as the bleeding originating from the gastrointestinal tract distal to the ligament of Treitz. LGIB is commonly caused by colonic diverticula, hemorrhoids, colorectal cancer, angiodysplasia, inflammatory bowel disease (IBD), and ischemic colitis. Although the diagnosis and management of LGIB have largely evolved with recent advancements, the incidence and trends of LGIB are unclear. We sought to look at the incidence and trends of LGIB 2002-2017 using a population level database. METHODS: Retrospective analysis of individuals ≥ 18 years who were hospitalized with LGIB was performed using a cloud database (IBM Explorys). Explorys aggregates de-identified data across 300 hospitals in the US. ICD 9 and ICD 10 diagnosis codes are mapped using SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) hierarchy. Using SNOMED CT codes, Individuals who had at least one inpatient encounter with SNOMED CT diagnosis code of LGIB were identified. The rates of hospitalization and annual percentage change (APC) due to various etiologies of LGIB was analyzed between 2002-2017 were calculated using Excel, 2016. RESULTS: Among a cohort of 51,770,740 unique patients, 2.31% hospitalizations in 2017 were due to LGIB. The most common diagnosis associated with LGIB were hemorrhoids (34.56%) followed by diverticular disease (20.03%), IBD (3.23%), colorectal cancer (2.56%), vascular insufficiency including ischemic colitis (1.26%) and angiodysplasia (0.83%). The rates of hospitalization due to LGIB increased from 0.35% in 2002 to 2.31% in 2017 (Figure 1). The APC of LGIB based on etiology is depicted in Figure 3. There was no statistically significant difference when the mean APC of the overall cases of LGIB was compared to the mean APC of individual etiologies. CONCLUSION: The rates of lower gastrointestinal bleeding requiring hospitalization and inpatient management have significantly increased over the last 2 decades. Among LGIB hospitalizations, the proportion of hemorrhoids and CRC have decreased while that of diverticular disease and angiodysplasia have increased over 5-year intervals (Table 1). Patient awareness, better diagnostic techniques, and aging population probably contribute to the increase in the rates of LGIB.

Endoscopic Therapy for Acute Diverticular Bleeding.

Diverticular bleeding accounts for approximately 26%–40% of the cases of lower gastrointestinal bleeding. Rupture of the vasa recta at the neck or dome of the diverticula can be the cause of this bleeding. Colonoscopy aids in not only the diagnosis but also the treatment of diverticular bleeding after a steady bowel preparation. Endoscopic hemostasis involves several methods, such as injection/thermal contact therapy, clipping, endoscopic band ligation (EBL), hemostatic powder, and over-the-scope clips. Each endoscopic method can provide a secure initial hemostasis. With regard to the clinical outcomes after an endoscopic treatment, the methods reportedly have no significant differences in the initial hemostasis and early recurring bleeding; however, EBL might prevent the need for transcatheter arterial embolization or surgery. In contrast, the long-term outcomes of the endoscopic treatments, such as a late bleeding and recurrent bleeding at 1 and 2 years, are not well known for diverticular bleeding. With regard to a cure for diverticular bleeding, there should be an improvement in both the endoscopic methods and the multilateral perspectives, such as diet, medicines, interventional approaches, and surgery.

Endoscopy, angiography, surgery: diagnostic and therapeutic algorithms for diverticular bleeding

Diverticular bleeding is acomplication of diverticular disease but in contrast to diverticulitis, publications concerning diverticular bleeding are less common. Diverticular bleeding is the cause of approximately 20-50% of cases of lower gastrointestinal bleeding and in rare cases can be life-threatening. The main symptom of diverticular hemorrhage is painless hematochezia and the German guidelines recommend that further diagnostics of suspected diverticular bleeding should be performed in hospital. Interdisciplinary diagnostic and therapeutic algorithms recommend primary endoscopy in acute as well as chronic recurrent diverticular bleeding. If endoscopy fails to provide an exact localization of the origin of bleeding, angiography or computed tomography (CT) angiography can be performed. The 99mTc erythrocyte scintigraphy should only be performed if endoscopy and angiography are unable to identify the localization of the bleeding source. More than 90% of diverticular hemorrhages stop spontaneously; however, it is general agreed that an active diverticular bleeding detected during colonoscopy should be immediately treated endoscopically. Alternative radiological techniques for hemostasis are rarely needed and attention must be paid to the complications. In the rare case of severe bleeding that cannot otherwise be stopped or if the bleeding vessel cannot be located, laparotomy and total colectomy can be recommended. If the diverticular bleeding has definitely been identified or recurrent bleeding causes chronic anemia, segmental or total colectomy may be undertaken; however, the advantages and disadvantages of both types of surgery have to be thoroughly explained to the patient.

Urgent Surgical Management of Acute Lower Gastrointestinal Bleeding with Intraoperative Colonoscopy: A Case Report

Lower gastrointestinal bleeding (LGIB) is defined as bleeding from a source distal to the Ligament of Treitz. The primary step is to identify severe hemorrhages that may be life-threatening for patients (10% of cases of LGIB). The management depends on the severity of the bleeding, the diagnostic and therapeutic means of the patient’s reception center. Patient with acute LGIB, in case of negativity of endoscopic and radiological examinations, can be a surgical indication with possibility of intraoperative colonoscopy. We report a case of urgent surgical management with intraoperative colonoscopy in a patient with severe acute LGIB.

Management of Acute Lower Gastrointestinal Bleeding

Acute lower gastrointestinal bleeding (LGIB), defined as hemorrhage into the gastrointestinal tract distal to the ligament of Treitz, is a major cause of morbidity and mortality among adults. Overall, mortality rates are estimated between 2.4% and 3.9%. The most common etiology for LGIB is diverticulosis, implicated in approximately 30% of cases, with other causes including hemorrhoids, ischemic colitis, and postpolypectomy bleeding. Transcatheter visceral angiography has begun to play an increasingly important role in both the diagnosis and treatment of LGIB. Historically, transcatheter visceral angiography has been used to direct vasopressin infusion with embolization reserved for treatment of upper gastrointestinal bleeding. However, advances in microcatheter technology and embolotherapy have enabled super-selective embolization to emerge as the treatment of choice for many cases of LGIB.

BLEED: a classification tool to predict outcomes in patients with upper and lower gastrointestinal hemorrhage

Background: Acute gastrointestinal (GI) haemorrhage is a common clinical problem with diverse manifestations. Such bleeding may range from trivial to massive and can originate from virtually any region of the GI tract, including the pancreas, liver, and biliary tree. Several risk scoring systems have also been proposed to classify patients into high and low risk groups for complications, like re-bleeding or mortality, based on multivariate analyses. Kollef and colleagues identified the BLEED criteria: (a) ongoing Bleeding, (b) Low systolic blood pressure (BP), (c) Elevated prothrombin time (PT), (d) Erratic mental status, and (e) unstable comorbid Disease as risk factors for complication of GIH at any time during hospitalization after an initial 24 hours of stabilization. The objective of this study was to predict outcome according to a risk stratification BLEED criterion, independent of endoscopic findings.Methods: We studied all patients who presented with acute gastrointestinal bleeding to emergency department. patients with epistaxis, paranasal sinuses bleed, upper GI bleed secondary to endoscopic procedure, patients with chronic Anemia and those patients which admitted with Primary diagnosis other than UGIB were excluded. Patients meeting the BLEED criteria at their initial assessment were classified as high risk (66) and all others were categorized as low-risk (10). In-hospital complications were defined as recurrent UGIB, surgery to control the source of hemorrhage, hospital mortality, length of hospital stay and units of blood transfused.Results: There were 76 patients, with mean age of 46.37 years, 56 patients (73.3%) were case of Upper gastrointestinal bleeding, 20 patients (26.7%) were case of lower gastrointestinal bleeding. 66 (86.84%) of patients were categorized as high-risk patients and 10(13.2%) of patients were categorized as low risk patients. 14(21.1%) of patients were admitted in ICU ,13 Patients had undergone surgery (17.10%), 1 (1.5%) of patient had Re bleeding, nine (13%) had died. Stastical analysis showed significant association between components like low SBP (P=0.008), elevated prothrombin time (P=0.04), erratic mental status(P=0.001) and in hospital complications. All nine deaths were found in high risk group.Conclusions: BLEED criteria can be used as triage tool for stratifying the patients of acute gastrointestinal haemorrhage into high risk and low risk category without endoscopic findings and useful in predicting outcome in such patients and plan the treatment accordingly.

Hematochezia due to Angiodysplasia of the Appendix.

Common causes of lower gastrointestinal bleeding include diverticular disease, vascular disease, inflammatory bowel disease, neoplasms, and hemorrhoids. Lower gastrointestinal bleeding of appendiceal origin is extremely rare. We report a case of lower gastrointestinal bleeding due to angiodysplasia of the appendix. A 72-year-old man presented with hematochezia. Colonoscopy showed active bleeding from the orifice of the appendix. We performed a laparoscopic appendectomy. Microscopically, dilated veins were found at the submucosal layer of the appendix. The patient was discharged uneventfully. Although lower gastrointestinal bleeding of appendiceal origin is very rare, clinicians should consider it during differential diagnosis.

A Rare Case of Lower Gastrointestinal Bleeding from Appendiceal Orifice Treated with Colonoscopic Appendiceal Clipping

Purpose: An 89-year-old male with past medical history of hypertension, prostate surgery and peptic ulcer disease diagnosed 20 years ago, presented with two sudden episodes of bloody diarrhea. The bowel movements were two hours apart and not associated with abdominal pain. He denied any previous episodes of bloody BM, preceding diarrhea or recent illness. His home medications included daily Aspirin and Norvasc. He recently immigrated to United States from China, and had a normal colonoscopy three years prior. His vital signs were temperature 98.4°F, blood pressure 119/80 mmHg, pulse 113 beats/min, respiratory rate 22 breaths/min, and oxygen saturation 100% on room air. On physical examination, his abdomen was soft, non-distended, non-tender, with normal bowel sounds and no guarding or rebound. Digital rectal exam revealed bright red blood and prolapsed external hemorrhoids. Initial laboratory data revealed hemoglobin 15.3 GM/DL, hematocrit 44.1% but repeat CBC after 2 hours revealed a hemoglobin 8.2 GM/DL and hematocrit 24.2%. The remaining laboratory values were normal. Gastric lavage was performed with retrieval of bilious material. He received IVF resuscitation, PRBC transfusion and was placed on a PPI drip. Upper endoscopy did not reveal any bleeding source. The patient was rapidly prepped with golytely and underwent colonoscopy, which revealed active bleeding from the appendiceal orifice. Periphery of the appendiceal orifice was injected with 1:10,000 epinephrine in four quadrants, followed by application of five hemoclips over the appendiceal orifice with good hemostasis. Post-colonoscopy abdominal computed tomography showed the cecum in the left side of the abdomen and an irregular thickening of the appendix wall, but tumor could not be excluded. After colonoscopy, the patient's hemoglobin and hematocrit gradually improved and no signs or symptoms of appendicitis developed. On hospital day four, the patient underwent a partial cecectomy. Pathology revealed focal ulceration of the mucosa without malignancy. The remainder of the patient's hospital course was uneventful and he was discharged without further episodes of hematochezia. Appendiceal hemorrhage is an extremely rare cause of lower gastrointestinal bleeding with few cases reported in the English literature. The endoscopic methods utilized in this case proved effective in achieving hemostasis without complication of appendicitis and allowed the patient to be stabilized prior to surgical intervention.Figure: [1135]

Massive Lower Gastrointestinal Bleeding from the Appendix

Massive rectal bleeding from the appendix, considered a rare case of lower gastrointestinal bleeding, is not easily recognized by various diagnostic modalities. A multidisciplinary approach for both a diagnosis and a differential diagnosis is important because the identification of the bleeding site is crucial to proceed to a proper intervention and there are various causes of appendiceal bleeding. Because early colonoscopy plays an important role in the diagnosis and management of lower gastrointestinal hemorrhage, we report a case of a life threatening massive rectal bleeding from the appendix diagnosed by colonoscopy. We also present a review of the literature.

How to Place Hemoclips to Achieve Hemostasis of a Bleeding Diverticulum

Sir, We read with much interest the article by Dr. Yen regarding colonoscopic treatment of acute diverticular hemorrhage by use of endoclips. In the article the authors describe the peculiar technique of positioning hemoclips bridging the edge of the diverticulum. The clipping technique consists in applying the clip on the only fringe of the diverticular orifice, placing one prong within the adjacent mucosa and the other in the diverticulum, leaving its orifice open [1]. Although the authors did not declare any complication in the series presented, it is our opinion that such a manoeuver might be unreasonably dangerous. In fact, it is known that the wall of the diverticulum is constituted by a single mucosal layer, besides being inflamed. The introduction, mostly blind, of one of the two jaws of the clip into this cavity seems unnecessary. For several years it has been our policy to prefer compression hemostasis to injection techniques, to control diverticular bleeding. In a series of six patients recently treated, up to five hemoclips were sufficient to achieve hemostasis in all cases. Hemoclips were positioned bridging the entire diverticular orifice, in this way matching the two edges by compressing the entire enteric wall. In other words hemoclips are placed to close the whole diverticular orifice among the prongs of the clips. In this way it is possible to achieve both direct compression of the bleeding vessel, if running at the clipped edge, or at least indirect compression of the vessel. In no case was injection of any drug or any other treatment needed. One of these patients was a 77-year-old man admitted to ER for acute massive rectal bleeding. The patient was administered oral anticoagulant therapy for atrial fibrillation. Three years earlier he underwent a prophylactic left hemicolectomy for recurrent diverticulitis. On admission, hemoglobin was 9 mg/dl and INR was 2.01. Urgent colonoscopy revealed multiple diverticula throughout the entire colon with the presence of abundant blood and clots in all 70 cm of the remaining colon. A tightly adherent blood clot probably covering a diverticulum and significant blood spurting flow below it were seen 55 cm from anal verge, apparently in the transverse colon (Fig. 1a). The blood clot was removed by lavage, revealing underneath an actively bleeding diverticulum (Fig. 1b). Three hemoclips (Resolution clip; Microvasive Endoscopy, Boston Scentific, Natick, MA, USA) were placed across diverticulum until constant complete hemostasis was observed for 5 min. Hemoclips were placed to close the whole diverticular orifice among the prongs of the clips (Fig. 1c). Two hours later X-rays demonstrated no free air, and the three clips were in place distal to the hepatic flexure (Fig. 1d). No further rectal bleeding was observed, and hemoglobin levels increased to 10.5 mg/dl two days later, when the patient was discharged. Bleeding from colonic diverticula is the most common cause of acute lower gastrointestinal bleeding [2]. Despite advances in diagnostic and therapeutic technology, 10–25% of cases of lower gastrointestinal bleeding will require surgical intervention because of patient instability [3]. Colonoscopy enables simultaneous diagnosis and treatment; however, controversies exist concerning the clinical impact, timing, and modalities of application. Among the techniques available, only hemoclips treatment has been reported to control bleeding in 100% of cases [1]. This successful case series adds to those already published, A. Arezzo (&) M. Verra F. Cravero R. Reddavid M. Morino Digestive, Colorectal and Minimally Invasive Surgery, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy e-mail: alberto.arezzo@unito.it

A Case of Lower Gastrointestinal Bleeding Caused by Primary Iliac Arterio-colic Fistula

Arterio-enteric fistula is a very rare cause of massive lower gastrointestinal hemorrhage. We report here on a case of massive hematochezia caused by iliac arterio-colic fistula in a 60-year-old woman who had a recent history of spinal surgery for herniated nucleus pulposus. Abdomen computed tomography showed the extravasation of radiocontrast media from right iliac artery encased by an intraabdominal abscess into the adjacent dilatated colon. Also, diagnostic angiography revealed the active extravasation of radiocontrast media via a fistula between right iliac artery and colon. Although successful endovascular exclusion of the fistula with stent graft and coils was performed, disseminated intravascular coagulation and multi-organ failure were developed.

Lower gastrointestinal bleeding: Association with Sevelamer use

Stercoral ulceration results from impaction of hard fecal mass on the colonic wall and is a relatively unknown cause of lower gastrointestinal bleeding. In this report, we describe a case of lower gastrointestinal bleeding due to stercoral ulceration resulting from Sevelamer, a drug which is commonly associated with constipation.

Use of Provocative Angiography to Localize Site in Recurrent Gastrointestinal Bleeding

While the source of most cases of lower gastrointestinal bleeding may be diagnosed with modern radiological and endoscopic techniques, approximately 5% of patients remain who have negative endoscopic and radiological investigations [1]. These patients require repeated hospital admissions and blood transfusions, and may proceed to exploratory laparotomy and intraoperative endoscopy. The personal and financial costs are significant. The technique of adding pharmacologic agents (anticoagulants, vasodilators, fibrinolytics) during standard angiographic protocols to induce a prohemorrhagic state is termed provocative angiography. It is best employed when significant bleeding would otherwise necessitate emergency surgery. This practice frequently identifies a bleeding source (reported success rates range from 29 to 80%), which may then be treated at the same session. We report the case of a patient with chronic lower gastrointestinal hemorrhage with consistently negative endoscopic and radiological workup, who had an occult source of bleeding identified only after a provocative angiographic protocol was instituted, and who underwent succeeding therapeutic coil embolization of the bleeding vessel.

Appendicitis Presenting as Acute Lower Gastrointestinal Bleeding

Introduction: Appendicitis is the most common acute surgical condition of the abdomen; however, gastrointestinal bleeding is not a complication that is often seen. We report an unusual case of lower gastrointestinal bleeding with active bleeding from the appendix identified on colonoscopy from appendicitis. Case Report: A 63-year-old-woman with history of diverticulosis was admitted with one-day duration of hematochezia. She described a right lower quadrant abdominal pain a week prior to the bleeding which had resolved spontaneously. She had a screening colonoscopy 3 months prior which revealed pandiverticulosis. She was not on any anticoagulants and did not have any nausea, vomiting, fevers, or abdominal pain on presentation. In the ED, the patient was orthostatic and NG lavage was negative for blood. She was afebrile and there were no signs of an acute abdomen. A rectal exam revealed fresh blood. On admission the Hgb was 11.5 g/dl and no evidence of leukocytosis. A bleeding scan showed active bleeding in the cecum/ascending colon. Angiography showed no evidence of active bleeding. A colonoscopy performed after a rapid purge revealed left sided diverticulosis without active bleeding. The cecum and the appendiceal orifice was identified with the appearance of an adherent clot and active oozing of blood from the appendix (fig 1). There was abnormal polypoid appearance of the tissue surrounding the appendix (fig 2). Surgery was consulted and a right hemicolectomy was performed. The pathology revealed a pericecal/periappendiceal abscess. Bleeding from the appendix is a rare cause of lower GI bleeding. Unless there is massive bleeding, an urgent colonoscopy after a rapid purge can be effective in identifying and managing an acute LGIB. The cause of an isolated appendiceal bleed will determine management and surgical outcome. [figure 1][figure 2]Figure 1Figure 2

Successful treatment of massive acute lower gastrointestinal bleeding in diverticular disease of colon, with activated recombinant factor VII (NovoSeven)

Recombinant coagulation factor (rFVIIa) (NovoSeven; Novo Nordisk A/S, Copenhagen, Denmark) is registered in most regions in the world for the treatment of bleeding episodes in haemophilia with inhibitors to factor VIII or factor IX. The mechanism of action suggests that its enhancing effects in haemostasis are limited to the site of injury and that systemic activation of the coagulation cascade does not occur. We report a case of lower gastrointestinal bleeding in diverticular disease of the colon in an inoperable elderly patient without pre-existing coagulopathy, which has successfully treated with a single injection of rFVIIa. This experience suggests that rFVIIa, besides its actual high costs, might be a useful and safe, noninvasive therapeutic tool in selected cases of massive lower gastrointestinal bleeding in the elderly.

The Management of Lower Gastrointestinal Hemorrhage

Gastrointestinal hemorrhage is a common clinical problem, which accounts for approximately 1 to 2 percent of acute hospital admissions. The colon is responsible for approximately 87 to 95 percent of all cases of lower gastrointestinal bleeding, with the remaining cases arising in the small bowel. The etiology, diagnostic evaluation, management, and treatment options available for lower gastrointestinal hemorrhage were reviewed. A review of lower gastrointestinal bleeding was performed, which discussed the most common etiologies with a few rare and unusual causes. The current literature about different diagnostic techniques, management problems, and therapeutic options was reviewed. Current management strategies and treatment options for the many causes of lower gastrointestinal bleeding will be reviewed. A review of the different causes of lower gastrointestinal hemorrhage and available diagnostic studies was performed. Management strategies based on the etiology of the bleeding and results of the diagnostic studies were discussed. An algorithm was provided to develop a diagnostic and therapeutic treatment strategy for lower gastrointestinal hemorrhage. Lower gastrointestinal hemorrhage can be a difficult and frustrating problem to both the clinician and the patient. Knowledge of the available diagnostic tests to help identify the source of bleeding is essential to the practicing clinician. Once the source is identified, management strategies and available treatment options need to be specific for each individual case. This review will aid the practicing physician in developing an algorithm for lower gastrointestinal hemorrhage.