Lower gastrointestinal bleeding differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Several diseases present with lower gastrointestinal bleeding and must be differented from each other. The common diseases responsible for lower GI bleeding inlcude diverticulosis, angiodysplasia, hemorrhoids, anal fissures, mesenteric Ischemia, ischemic colitis, inflammatory bowel disease, and colorectal carcinoma.

Differentiating Lower gastrointestinal bleeding from other Diseases

Several diseases present with lower gastrointestinal bleeding and must be differented from each other. The common diseases responsible for lower GI bleeding inlcude diverticulosis, angiodysplasia, hemorrhoids, anal fissures, mesenteric Ischemia, ischemic colitis, inflammatory bowel disease, and colorectal carcinoma.

Disease Symptoms Other features Diagnosis
Abdominal pain Rectal pain Weightloss Fever Type of GI bleeding Diarrhea Constipation Laboratory findings Radio-Imaging findings
Diverticulosis - - - - Red or maroon-colored blood - +
  • Self limiting
  • Seen in elderly
Normal

Globular outpouchings on CT scan

Angiodysplasia - - - - Frank blood - - Normal Normal
Hemorrhoids - + - - Blood on tissues - + - Tortuous dilated vessels on anoscopy
Anal fissures - + - - Blood on tissues - + Normal except mild leucocytosis Anoscopy
Mesenteric Ischemia + - + + Frank blood + -
  • Pain alters with eating habits
  • Associated with other comorbid conditions
Ischemic colitis + - - + Frank blood + - 3 phases
  • Mild moderate diffuse bowel wall thickening
  • Marked hyperenhancement of the mucosa
Crohn's disease + - + + Blood mixed with stools + + Extra intestinal manifestations
Ulcerative colitis + + + + Blood mixed with stools + +
Colon carcinoma + -† + + Occult bleeding + +† + FOBT (fecal occult blood test)

↑ CEA( and CA 19-9

Hypercalcemia 

The following table differentiates all the diseases presenting with abdominal pain and lower gastrointestinal bleeding.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Acute diverticulitis LLQ + ± + + ± + Positive in perforated diverticulitis + + Hypoactive
  • CT scan
  • Ultrasound
Inflammatory bowel disease Diffuse ± ± + + + Normal or hyperactive

Extra intestinal findings:

Infective colitis Diffuse + ± + + Positive in fulminant colitis ± ± Hyperactive CT scan
  • Bowel wall thickening
  • Edema
Colon carcinoma Diffuse/localized ± ± + + ±
  • Normal or hyperactive if obstruction present
  • CBC
  • Carcinoembryonic antigen (CEA)
  • Colonoscopy
  • Flexible sigmoidoscopy
  • Barium enema
  • CT colonography 
  • PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction
Hemochromatosis RUQ Positive in cirrhotic patients N
  • >60% TS
  • >240 μg/L SF
  • Raised LFT
    Hyperglycemia
  • Ultrasound shows evidence of cirrhosis
Extra intestinal findings:
Mesenteric ischemia Periumbilical Positive if bowel becomes gangrenous + + + + Positive if bowel becomes gangrenous Positive if bowel becomes gangrenous Hyperactive to absent CT angiography
  • SMA or SMV thrombosis
  • Also known as abdominal angina that worsens with eating
Acute ischemic colitis Diffuse + ± + + + + + + + Hyperactive then absent Abdominal x-ray
  • Distension and pneumatosis

CT scan

  • Double halo appearance, thumbprinting
  • Thickening of bowel
  • May lead to shock
Ruptured abdominal aortic aneurysm Diffuse ± + + + + N
  • Focused Assessment with Sonography in Trauma (FAST) 
  • Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage Diffuse ± ± + + N
  • ↓ Hb
  • ↓ Hct
  • CT scan

References


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