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DOI: 10.1055/s-0045-1809364
Lower Gastrointestinal Bleeding: Etiology and Outcomes at a Tertiary Care Center in South India—Are These Different from the West?
Funding None.
Abstract
Background and Objectives
Lower gastrointestinal bleeding (LGIB) is a common clinical condition with limited prospective data from South Asia. This study aimed to describe the clinical characteristics, diagnostic evaluation, therapeutic interventions, and outcomes of patients with LGIB at a tertiary care center in South India.
Materials and Methods
This prospective observational study included 150 patients with LGIB from August 2023 to July 2024. Patient demographics, clinical presentation, diagnostic procedures, interventions, and outcomes were recorded. Patients were followed up until 28 days post-discharge.
Results
The mean age of the patients was 50 years, with a male predominance (72%). Colitis (26%) was the most common etiology, followed by benign anorectal disorders (19%). Diagnostic yield for LGI endoscopy was 61%. Endoscopic therapy was performed in 5% of patients, radiological intervention in 3%, and surgery in 7%. Rebleeding rate was 7.9%, and readmission rate was 6.6%. Overall mortality was 5.3%, with higher rates among inpatient LGIB compared with those admitted with LGIB (19.2% versus 2.4%, p = 0.004). Seven of the eight deaths were secondary to underlying comorbid illnesses.
Conclusion
The etiological spectrum of LGIB in this South Indian center differs from Western studies, with colitis being the predominant cause. Most patients were managed conservatively. Mortality rates were similar to Western studies and primarily attributed to underlying comorbidities. Further multicenter studies are needed to develop appropriate management guidelines for the South Asian region.
Introduction
Lower gastrointestinal bleeding (LGIB) refers to blood loss from a source distal to the ligament of Treitz.[1] The clinical spectrum of LGIB can be varied, ranging from self-limited melena or hematochezia to massive hemorrhage with shock.[2] It accounts for approximately 20% of all cases of gastrointestinal bleeding, which in many instances requires extensive diagnostic workup and usage of health resources.[3] Though literature from the West has described the clinical spectrum, patient characteristics, and outcomes of LGIB,[4] [5] [6] there is limited prospective data regarding this common clinical condition from South Asia. Hence, we aimed to describe the clinical characteristics, diagnostic evaluation, therapeutic interventions, and outcomes of patients with LGIB at our institution, a tertiary care center located in South India.
Materials and Methods
This was a single-center, prospective, observational study of patients with LGIB from August 2023 to July 2024 who fulfilled the inclusion and exclusion criteria. We included patients aged 16 years and above with a history of LGIB who were admitted for evaluation or who had at least one episode of LGIB while the patient was admitted for another clinical indication, and gave informed consent. Patients who did not give valid consent, those below the age of 16, those in whom upper gastrointestinal (UGI) endoscopic evaluation identified a cause for the LGIB, and those on a nasogastric (NG) tube which drained altered blood were excluded.
Patient details including demographics, type of presentation, mode of onset, whether presenting with LGIB or an existing in-patient who developed an LGIB, vitals and inotrope requirements, comorbid illnesses and Charlson comorbidity index (CCI), medication history, addictions, health status based on American Society of Anesthesiologists (ASA) classification, and per rectal (PR) examination findings were recorded on a pre-designed proforma.[7] [8] The endoscopic findings, interventions performed, and the time to LGI endoscopy were recorded, as also whether the endoscopy was repeated. The requirement for contrast-enhanced computed tomography (CECT) of abdomen, interventional radiological procedures or surgery, and need for blood products were also recorded.
The diagnostic algorithm followed in the study is depicted in [Fig. 1]. We performed CT angiography (CTA) in patients with hemodynamic instability despite resuscitation and in those where a bleeding source was not identified after successful resuscitation and a colonoscopy. CT enterography (CTE) was performed when colonoscopy failed to identify a bleeding source, in patients with no active hematochezia or hemodynamic compromise. Capsule endoscopy was performed in patients in whom a small bowel source was suspected after unyielding gastroscopy, colonoscopy, and CTA/CTE failed to localize the bleeding source.
Patients were followed up until 28 days post-discharge. Important outcomes such as duration of hospitalization, intensive care unit (ICU)/high dependency unit (HDU) support, need for readmission, and occurrence of death were recorded. Management of patients on antiplatelets and anticoagulation was based on existing guidelines.[9] However, individualized treatment plans were made in some patients based on the treating clinician's decision. The institutional review board approved the study (IRB Min No. 12013).
Definitions used in the study were mainly based on the large multi-centric study by Oakland et al[4]:
-
LGIB: Hematochezia or melena without hematemesis.
-
Acute LGIB: Duration of onset of bleed ≤3 days.[10]
-
Clinically significant bleeding: Systolic blood pressure (SBP) <100 mm Hg, heart rate (HR) ≥100/minute, and ≥1 unit of packed red blood cell (PRBC) transfusion.
-
Shock: HR ≥100/minute and SBp <100 mm Hg.
-
Rebleeding: Additional PRBC requirement and/or a reduction in hematocrit by ≥20% after 24 hours of hemodynamic stability.
-
Readmission: An unplanned admission due to further LGIB within 28 days of discharge.
-
28-day follow-up mortality: Death within 28 days of discharge from the hospital.
-
Current smoker: Adults who have smoked ≥100 cigarettes in his/her lifetime and within the last 28 days.[11]
-
Heavy alcohol use: Consumption of >14 drinks/week in males or >7 drinks/week in females.[12]
-
Obscure overt GI bleed (OOGIB): When the source of bleeding is not found even after the performance of standard upper and lower endoscopic examinations, small bowel evaluation with video capsule endoscopy (VCE) and/or enteroscopy, and radiographic testing.[13]
Statistical Analysis
In the study by Oakland et al, the occurrence of rebleed was 13.6%, and readmission was 10.3%.[4] Assuming the composite outcome of rebleed or readmission to be approximately 20% and keeping a precision of 6.5% with a 95% confidence interval, the sample size for our study was estimated to be approximately 150 patients with LGIB.
Categorical variables were expressed as frequencies and percentages, while continuous variables were expressed as mean and/or standard deviation or as median with a range of values. A p-value <0.05 was considered significant. Quantitative data between groups were compared using Student's t-test for parametric data and Mann–Whitney U test for nonparametric data. Categorical variables were compared using the appropriate chi-square or Fisher's exact test.
Results
A total of 150 patients with LGIB fulfilling inclusion and exclusion criteria were included in the study cohort. The cohort included patients predominantly from South India, mainly from Tamil Nadu (38%) and Andhra Pradesh (16%). The cohort consisted of 124 (82.6%) patients admitted with LGIB, while the remaining 26 (17.3%) were in-patients who developed LGIB while being admitted for another ailment (in-patient bleeds). Baseline characteristics are depicted in [Table 1]. The mean (SD) age was 50 (16) years with a male predominance (72%). Median CCI was 2 (range: 0–4). Cardiovascular disease and diabetes mellitus were the most common comorbidities. Comorbidities were significantly higher among in-patient bleed than those who presented with LGIB (100% vs. 72%, p < 0.001). Clinically significant bleed was found in 12%. Among the 145 patients who ever underwent endoscopic evaluation for LGIB, the diagnostic yield for LGI endoscopy was 61%.
Abbreviations: AP&AC, antiplatelet and anticoagulant; ASA, American Society of Anesthesiologists; CCI, Charlson comorbidity Index; CVA, cerebrovascular accident; DAPT, dual antiplatelet therapy; LGIB, lower gastrointestinal bleeding; NSAID, nonsteroidal anti-inflammatory drug; PVD, peripheral vascular disease; SAPT, single antiplatelet therapy.
Note: aRepresents comparison between “admitted with LGIB” and “in-patient LGIB” groups. Figures are depicted only for significant P values.
At presentation, 33 (22%) patients were on antiplatelet agents, 15 (10%) were on anticoagulation, while 9 (6%) patients were on both.
Median (IQR) time from admission or primary gastroenterology consultation to LGI endoscopy was 29 hours (13–72). The most common etiology of LGIB was colitis (26%), followed by benign anorectal disorders (19%) ([Table 2]). Among colitis, inflammatory bowel disease (IBD)-related colitis was the predominant etiology (59%). Colitis (27%) was the most common etiology among patients admitted with LGIB, while benign anorectal disorders (27%) were the predominant source among inpatient bleeds. The most common etiologies among those >60 years of age were benign anorectal disorders (22%) and malignancy (14%), followed by angioectasiae (10%) and drug-induced causes (10%). Among those with <60 years of age common etiologies were colitis (35%), benign anorectal disorders (17%), and small bowel source (11%).
|
Diagnosis |
Total (n = 150) |
|---|---|
|
Colitisa (%) |
39 (26) |
|
Benign anorectal disorders[b] (%) |
28 (19) |
|
Malignancy[c] (%) |
14 (9) |
|
Small bowel source[d] (%) |
13 (8) |
|
Angioectasiae (%) |
10 (7) |
|
Drug-induced[e] (%) |
7 (4) |
|
Diverticular (%) |
5 (3) |
|
Polyp (%) |
3 (2) |
|
Others[f] (%) |
10 (7) |
|
OOGIB (%) |
5 (3) |
|
Unknown (%) |
16 (11) |
Abbreviations: LGIB, lower gastrointestinal bleeding; OOGIB, obscure overt gastrointestinal bleeding.
Note: aUlcerative colitis (19), radiation proctitis (4), Crohn's disease (4), infective dysentery (2), ischemic colitis (2), CMV colitis (1), colonic tuberculosis (1), colonic ulcers—non-specific (1), drug-induced colitis (1), immune-mediated colitis (3), infective colitis (1).
b Hemorrhoids (20), rectal ulcer (5), anal fissure (2), solitary rectal ulcer syndrome (1).
c Carcinoma colon (7), carcinoma rectum (3), small bowel adenocarcinoma (2), small bowel diffuse large cell B lymphoma (2).
d Small bowel neoplasm (6), small bowel Crohn's disease (3), small bowel vasculitis (2), CMV ileitis (1), anastomotic ulcer (1).
e Anticoagulant-induced GI bleed (5), NSAID enteropathy (1).
f Small bowel vascular malformation (4), thrombocytopenia-related bleed (4), GI amyloidosis (2).
The cause of LGIB could not be ascertained in 21 (14%) patients, of which 5 patients were considered OOGIB and the remaining 16 did not undergo complete evaluation and were deemed to have unknown etiology. Among patients with OOGIB, only two patients had further bleeding and were readmitted. However, these did not require any further transfusion or intervention up to the end of follow-up. Among the 16 patients with unknown etiology due to incomplete assessment, 11 had evaluation using upper GI and lower GI endoscopy along with CT imaging while 5 had endoscopy alone.
Endoscopic therapy was done in 7 (5%) patients, radiological intervention (mesenteric artery embolization) in 5 (3%), and surgery in 10 (7%) ([Table 3]).
|
Parameter |
Admitted with LGIB (n = 124) |
In-patient LGIB (n = 26) |
Total (n = 150) |
|---|---|---|---|
|
Diagnostic procedures (%) |
|||
|
Sigmoidoscopy (%) |
21 (17) |
6 (23) |
27 (18) |
|
Colonoscopy (%) |
96 (77) |
14 (54) |
110 (73) |
|
Small bowel enteroscopya (%) |
7 (6) |
2 (8) |
9 (6) |
|
Capsule endoscopy (%) |
17 (14) |
0 |
17 (11) |
|
No endoscopy (%) |
5 (4) |
6 (2) |
11 (7) |
|
CT of abdomen (%) |
86 (69) |
15 (58) |
101 (67) |
|
Transfusion requirement (%) |
79 (64) |
21 (81) |
100 (67) |
|
PRBC transfusion (%) |
74 (60) |
20 (77) |
94 (63) |
|
>4 units PRBCs (%) |
10 (8) |
3 (12) |
13 (9) |
|
FFPs (%) |
6 (5) |
6 (23) |
12 (8) |
|
Platelets (%) |
7 (6) |
5 (19) |
12 (8) |
|
Cryoprecipitate (%) |
2 (2) |
2 (8) |
4 (3) |
|
Factor support (%) |
1 (1) |
0 |
1 (1) |
|
Interventional procedures (%) |
|||
|
Endotherapy (%) |
6 (5) |
1 (4) |
7 (5) |
|
Adrenaline injection (%) |
1 (1) |
0 |
1(1) |
|
Hemoclips (%) |
0 |
0 |
0 |
|
APC (%) |
4 (3) |
0 |
4 (3) |
|
Gold probe (%) |
0 |
0 |
0 |
|
Dual therapy (%) |
1[b] (1) |
1[c] (4) |
2 (1) |
|
Interventional radiology (%) |
3 (2) |
2 (8) |
5 (3) |
|
Surgery (%) |
7 (6) |
3 (12) |
10 (7) |
|
ICU/HDU care (%) |
14 (11) |
9 (34) |
23 (15) |
Abbreviations: APC, argon plasma coagulation; CT, computed tomography; FFP, fresh frozen plasma; ICU/HDU, intensive care unit/high dependency unit; IR, interventional radiology; LGIB, lower gastrointestinal bleeding; PRBC, packed red blood cell.
Note: aIncludes double balloon enteroscopy, push enteroscopy, on-table enteroscopy, power spiral enteroscopy.
b Hemoclip + APC.
c Adrenaline injection + Gold probe.
Our study showed a rebleeding rate of 7.9% (11/139) among patients who underwent endoscopic evaluation during current admission ([Table 4]), of which 9 did not undergo a repeat endoscopy (due to improvement with steroids for colitis or having undergone surgery or were moribund). Two underwent repeat colonoscopy followed by capsule endoscopy which showed multiple small bowel angioectasiae. Univariate analysis showed that requirement of more than 4 units of PRBC was significantly associated with the occurrence of rebleeding, while the use of antiplatelets and/or anticoagulation did not ([Supplementary Table S1], available in the online version). Angioectasiae was the most common etiology among those who rebled (4/11). Three of the four patients with rebleeding due to angioectasiae were from the small bowel.
Abbreviation: LGIB, lower gastrointestinal bleeding.
Note: aAmong those who underwent endoscopic evaluation for LGIB in the current admission (n = 139).
Overall, nine patients had a repeat colonoscopy: seven for further bleeding and two were repeated to perform endotherapy. Readmission was required in 10 (6.6%) patients for bleeding within 28 days of discharge.
Overall mortality was 5.3% (8/150). Mortality was greater among in-patient LGIB compared with those admitted with LGIB (19.2% versus 2.4%, p = 0.004). The cause of death in seven patients was sepsis with severe comorbid illnesses. Only in one patient was death attributed to uncontrolled bleeding. On univariate analysis, in-patient bleeds, acute onset of bleed, and shock at presentation were significantly associated with mortality ([Supplementary Table S2], available in the online version).
Discussion
Majority of the patients in our study were males, which was similar to most other studies with the exception of the study by Oakland et al wherein females were predominant.[2] [4] [14] [15] [16] [17] [18] Indian studies including ours had patients mainly in the 4th and 5th decades of life while the Japanese and Western studies had those in the 8th decade.[4] [14] [15] [16] [17] [18] Key findings across major studies from India and other countries are depicted in [Table 5].
Abbreviations: UC, Ulcerative colitis; IBD, inflammatory bowel disease; IP, in-patient; LNH, lymphoid nodular hyperplasia.
The etiological spectrum of LGIB is diverse across populations and study settings. The large UK multicenter audit by Oakland et al had shown diverticular bleeding and benign anorectal conditions as the leading causes of LGIB.[4] Diverticular bleeding was also the most common cause of LGIB in other studies from Europe and the USA.[5] [14] [19] However, Bai et al in their cohort of 720 patients and an accompanying systematic review including 160 studies (53,951 patients) from China showed colitis and colorectal carcinoma, respectively, as the leading causes.[2] Although studies from Japan in the past had shown colitis as the leading cause of LGIB, diverticulosis was the predominant etiology in a recent multicentric study from the same region.[15] [20] [21]
Studies from northern, eastern, and southern parts of India have shown varying non-diverticular etiologies such as IBD colitis, benign anorectal disorders, and polyps respectively, as the major causes of LGIB.[16] [17] [18] [22] [23] Our results are also in tandem with those from Goenka et al and the Chinese cohort with colitis (IBD-related and other causes of colitis) being the major etiology of LGIB.[2] [16] The difference in etiologies of LGIB in Western studies compared with our cohort could be attributed to older patients in their study group and differences in diet.[16]
The inability to localize the source of bleeding in our study was similar to the other studies, ranging from 3 to 30%.[2] [4] [14] [15] [16] [17] [18] [24] [25] This situation creates considerable anxiety among both patients and gastroenterologists alike. Data on outcomes in patients with OOGIB are unavailable from India or South Asia. However, multiple studies from the West have shown similar results as ours, wherein patients with negative capsule endoscopy have favorable outcomes with low rebleeding rates, fewer transfusion requirements, and lower healthcare utilization in future.[26] [27] [28] We suggest that this be highlighted to patients while discussing the need for capsule endoscopy evaluation in LGIB, when endoscopy and radiologic imaging are unyielding.
Majority of our patients (85%) were managed conservatively. However, the Japanese multicentric study showed high rates of endotherapy (30%). The low endotherapy rate (5%) in our study could be attributed to colitis being the predominant etiology, which is mostly managed medically. Dar et al from India have also reported high rates of endotherapy (38%), possibly due to polypectomy required for managing polyps, the most common etiology in their series.[18]
Compared with our cohort, the UK audit by Oakland et al had higher rebleeding rate (13.6%) but a similar readmission rate (4.4%).[4] Rebleeding rates across other studies ranged from 8 to 15.2%, similar to our cohort.[14] [15] [29] The severity of initial bleeding may be associated with a higher incidence of rebleeding, as evidenced by the significant association between the requirement of more than four packed red blood cell transfusions and subsequent rebleeding episodes. Unlike the UK audit,[4] use of antiplatelet or anticoagulation was not associated with rebleed in our study.
Mesenteric artery embolization is considered a life-saving tool in the therapeutic armamentarium for LGIB in patients who fail endotherapy and those in whom endoscopy may not be feasible due to hemodynamic instability before surgery is considered. Embolization rates similar to ours ranging from 0.3 to 1.4% were described in various other studies.[4] [14] [15]
A surgical approach is generally the last resort in managing LGIB, except for a few conditions, such as active hemorrhoidal bleeding, in which it is considered the first line. Based on the predominant pattern of etiology of LGIB and available expertise, various studies have reported rates of surgical intervention ranging from 0.2 to 21%. Recent studies have reported lower surgical intervention rates than older cohorts. Longstreth et al in 1997 reported a 16% surgical intervention rate, while an Italian study had only 7.1% of subjects requiring the same.[14] [30] Our cohort had a surgical intervention rate of 7%.
The mortality rate in our study was 5.3%. The rate of mortality was significantly higher among in-patient bleed patients as compared with those admitted with LGIB, further reiterating the impact of underlying comorbid illnesses on fatal outcomes in patients with LGIB. In-patient bleeds, acute onset of bleed, and shock at presentation were significantly associated with mortality. Longstreth et al have also reported similar findings wherein mortality rates were higher in in-patient bleeds than those who were admitted for LGIB, which was likely linked to a nosocomial complication or severe underlying illness rather than the LGIB per se.[30] The mortality rate in our study was comparable to the UK and Italian cohorts (3.4% in both)[4] [14] but higher than the Japanese study (0.9%). This difference might have likely resulted owing to the exclusion of those with those with in-patient bleeds in the latter.[15]
The strengths of our study were that it was a prospectively conducted study that captured data from admission and assessed outcomes up to 28 days post-discharge in all patients. Most of our patients were evaluated reasonably in detail for the source of bleed utilizing advanced endoscopic and radiological modalities. This is the first study from South Asia to assess outcomes of LGIB comprehensively.
Our study had limitations. The study was restricted to a single center and had a small sample size. The data may not be truly reflective of the LGIB at the general population level as ours was conducted in a tertiary care center setting. Conclusive prediction of risk factors for rebleeding and mortality was affected by the low numbers.
In conclusion, the etiological spectrum of LGIB in our center differs from those described in the West, with colitis being the predominant etiology in the former. The mortality rate was similar to the West and was mostly attributed to the underlying comorbid illnesses. Majority of our patients could be managed conservatively. Future multicentric studies with larger sample sizes will give more insight into the actual characteristics and outcomes of LGIB in the South Asian region, which can help create appropriate management guidelines.
Conflict of Interest
Amit Kumar Dutta and Sudipta Dhar Chowdhury are editors in the journal. The editors do not participate in any decision or peer review of the manuscripts they are authors.
Authors' Contributions
N.V.M.: Study design, data collection, patient follow-up, formal analysis, original draft preparation, and final approval of the manuscript.
E.G.S.: Conceptualization, study design, methodology, formal analysis, data curation, review and editing, and final approval of the manuscript.
A.J.: Study design, data collection, patient follow-up, formal analysis, review and editing, and final approval of the manuscript.
L.J.: Study design, methodology, formal analysis, review and editing, and final approval of the manuscript.
A.J.J.: Study design, methodology, review and editing, and final approval of the manuscript.
A.M.K.: Study design, methodology, review and editing, and final approval of the manuscript.
R.T.K.: Methodology, review and editing, and final approval of the manuscript.
R.J.: Study design, review and editing, and final approval of the manuscript.
S.D.C.: Study design, review and editing, and final approval of the manuscript.
Ethical Approval
The study was approved by the Institutional Review Board (IRB Minute No.: 12013) (OBSERVE) dated April 24, 2019 and Institutional Ethics Committee.
Patients' Consent
All patients included in the study provided informed written consent to publish the study data.
-
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Artikel online veröffentlicht:
27. Mai 2025
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References
- 1 Edelman DA, Sugawa C. Lower gastrointestinal bleeding: a review. Surg Endosc 2007; 21 (04) 514-520
- 2 Bai Y, Peng J, Gao J, Zou DW, Li ZS. Epidemiology of lower gastrointestinal bleeding in China: single-center series and systematic analysis of Chinese literature with 53,951 patients. J Gastroenterol Hepatol 2011; 26 (04) 678-682
- 3 Strate LL, Gralnek IM. ACG clinical guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol 2016; 111 (04) 459-474
- 4 Oakland K, Guy R, Uberoi R. et al; UK Lower GI Bleeding Collaborative. Acute lower GI bleeding in the UK: patient characteristics, interventions and outcomes in the first nationwide audit. Gut 2018; 67 (04) 654-662
- 5 Hreinsson JP, Gumundsson S, Kalaitzakis E, Björnsson ES. Lower gastrointestinal bleeding: incidence, etiology, and outcomes in a population-based setting. Eur J Gastroenterol Hepatol 2013; 25 (01) 37-43
- 6 Zuccaro G. Epidemiology of lower gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2008; 22 (02) 225-232
- 7 Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45 (06) 613-619
- 8 Doyle DJ, Hendrix JM, Garmon EH. American Society of Anesthesiologists Classification. August 17, 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
- 9 Veitch AM, Radaelli F, Alikhan R. et al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70 (09) 1611-1628
- 10 Davila RE, Rajan E, Adler DG. et al; Standards of Practice Committee. ASGE guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest Endosc 2005; 62 (05) 656-660
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