From the Guidelines
Management of hematochezia requires prompt assessment and targeted interventions based on severity, with urgent endoscopy being the cornerstone of diagnosis and treatment, and colonoscopy being the preferred initial procedure for most cases of hematochezia. For mild cases with minimal bleeding and stable vital signs, outpatient management may be appropriate with close follow-up 1. Moderate to severe hematochezia necessitates immediate medical attention, often requiring hospital admission for resuscitation and diagnosis. Initial management includes:
- Establishing two large-bore IV lines
- Fluid resuscitation with crystalloids
- Blood transfusion if hemoglobin is below 7-8 g/dL or if the patient is hemodynamically unstable Urgent endoscopy is crucial, with colonoscopy being the preferred initial procedure for most cases of hematochezia, as it allows for diagnosis and treatment of the underlying cause, such as diverticular bleeding, hemorrhoids, or angiodysplasia 1. If bleeding is massive or the patient is unstable, upper endoscopy should be performed first to rule out an upper GI source. Therapeutic options during endoscopy include:
- Epinephrine injection (1:10,000 dilution)
- Thermal coagulation
- Clip placement
- Band ligation depending on the bleeding source. For diverticular bleeding, endoscopic clipping is often effective, while for hemorrhoids, rubber band ligation or sclerotherapy may be used 1. Angiography with embolization is considered when endoscopy cannot identify or treat the bleeding source. Medical management includes correction of coagulopathy with vitamin K (10 mg IV), fresh frozen plasma, or prothrombin complex concentrate as needed, and proton pump inhibitors (e.g., pantoprazole 40 mg IV twice daily) are administered if upper GI bleeding is suspected 1. Once stabilized, identifying and addressing the underlying cause is essential to prevent recurrence, which may include management of diverticular disease, inflammatory bowel disease, or vascular abnormalities.
From the Research
Management of Hematochezia
- Hematochezia is a common clinical presentation with significant morbidity and economic burden, often requiring costly interventions including hospitalization, blood transfusions, and radiologic or endoscopic procedures 2.
- The cause of hematochezia can be diverse, including diverticulosis, angiodysplasia, neoplasm, perianal disorders, Meckel's diverticulum, colitis, and intussusception, with lower gastrointestinal bleeding mostly occurring in older age 3.
- A step-wise approach to hematochezia is recommended, beginning with hemodynamic assessment and risk stratification, then focused history and physical examination, endoscopic intervention when warranted, and consideration of small bowel bleeding in selected instances 2.
- The evaluation of the patient with hematochezia can be complex due to the broad differential diagnosis and the number of management strategies available, requiring a simplified approach to history and physical examination 4.
- Clinical symptoms associated with hematochezia, such as the amount and frequency of bleeding, weight loss, and change in bowel habits, may not reliably predict the presence of significant colonic lesions, highlighting the importance of endoscopic examination 5.
- Management of patients with severe hematochezia may involve routine urgent colonoscopy, with the goal of finding a definitive bleeding site and achieving hemostasis, although further randomized controlled trials are warranted to inform best practices 6.
Diagnostic Approaches
- Anoscopy and colonoscopy are essential diagnostic tools in the evaluation of hematochezia, with flexible sigmoidoscopy able to demonstrate most substantial lesions 5.
- Radiologic procedures, such as arteriography, may also be useful in selected cases 3.
- A thorough history and physical examination are crucial in guiding the diagnostic approach and identifying patients at high risk for significant bleeding or underlying pathology 2, 4.
Treatment Strategies
- Endoscopic intervention, such as colonoscopic hemostasis, may be effective in controlling bleeding and preventing recurrence 2, 6.
- Medical management, including the use of anticoagulants and antiplatelet agents, must be carefully considered in patients with hematochezia, with individualized decisions based on the underlying cause of bleeding and patient comorbidities 2, 6.
- Surgical intervention may be necessary in cases of severe or refractory bleeding, or when endoscopic or medical management is unsuccessful 3, 6.