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Risk of Recurrence and Death After Lower GI Bleeding



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Am Fam Physician. 2005 Sep 1;72(5):904-906.

The rate of hospitalization for persons with lower gastrointestinal (GI) bleeding is approximately 20 per 100,000 overall, increasing to 205 per 100,000 for persons 80 years or older. Little information is available on the rate of rebleeding or the long-term prognosis of this common condition. Anthony and colleagues studied the records of 119 patients admitted to one hospital because of lower GI bleeding and documented the rebleeding risk and survival rate.

The study included all patients who underwent technetium-99–labeled red blood cell scans for presumed lower GI bleeding from 1997 through 2002 at a Veterans Affairs medical center. Demographic and clinical information was collected for all patients, and follow-up continued for a median of 16 months.

All patients except two (3 percent) were men, and the average age was 70 years (range, 45 to 88). The presentation in 102 patients (86 percent) was passage of fresh blood rectally. Endoscopy was performed on 93 patients (78 percent), 19 of whom proceeded to surgery. Seven patients went directly to surgery without endoscopy. The most common surgical procedure was right hemicolectomy, which was performed on 10 patients. Other procedures were sigmoid colectomy, left hemicolectomy, total colectomy, small bowel resection, and hemorrhoidectomy. Fourteen of the 26 surgically treated patients were diagnosed with diverticular disease; other diagnoses included angiodysplasia, ischemic colitis, and post-polypectomy bleeding. Four patients (15 percent) died within 30 days of surgery.

Regardless of treatment, 102 patients survived the initial episode of lower GI bleeding by at least two weeks. During the median follow-up of 16 months, 14 patients (14 percent) had clinically significant rebleeding. The authors calculate the rebleeding rate as 9 percent at one month, 13 percent at one year, and 15 percent at two years. Statistical analysis to identify factors associated with the risk of rebleeding showed no significant prognostic associations, but there was a trend towards surgical or embolic treatment of the presenting episode. Forty patients died during the study; the median survival duration was 60 months after lower GI bleeding. The most common causes of death were sepsis, myocardial dysfunction, and cancer. One patient died from bleeding after refusing surgery.

The overall rate of rebleeding following lower GI bleeding in this case series (14 percent) and the calculated risk (9 percent at one month, 13 percent at one year, 15 percent at two years) are consistent with a 1997 population-based study of patients with bleeding from diverticulosis. The authors conclude that, although diverticulosis appears to be the most common cause of rebleeding, no prognostic factors can be identified from this study. However, the incidence of rebleeding appears to be low, and recurrence can be localized accurately at least as quickly as in the initial episode. The authors emphasize that more than one half of patients who rebled presented within one month, and 80 percent within one year. They also stress that the substantial mortality following lower GI bleeding is rarely attributable to hemorrhage.

Anthony T, et al. Rebleeding and survival after acute lower gastrointestinal bleeding. Am J Surg. November 2004;188:485–90.

editor’s note: The study1 conducted by Anthony and colleagues provides useful information in the management of one group of patients with lower GI bleeding (i.e., older men with acute severe bleeding). The causes, appropriate interventions, and prognosis are quite different for other patients. In the general population, lower GI bleeding usually is nonacute and intermittent, and may even be unperceived.2,3 A large percentage of patients with lower GI bleeding who present to primary care, especially younger patients with slight bleeding, are diagnosed with local problems such as hemorrhoids.2 The risk of rebleeding appears to be linked to the cause of the bleeding and its severity and chronicity. In this study1 and elsewhere,3 although mortality seems influenced by these factors, it is determined most strongly by the comorbidities of the patient.—a.d.w.

 

REFERENCES

1. Anthony T, Penta P, Todd RD, Sarosi GA, Nwariaku F, Rege RV. Rebleeding and survival after acute lower gastrointestinal bleeding. Am J Surg. 2004;188:485–90.

2. Billingham RP. The conundrum of lower gastrointestinal bleeding. Surg Clin North Am. 1997;77:241–52.

3. Richard JR. Lower gastrointestinal problems. Monograph 266, Home Study Self-Assessment program. Leawood, Kan.: American Academy of Family Physicians, 2001.



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