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CC BY 4.0 · Journal of Digestive Endoscopy
DOI: 10.1055/s-0045-1811957
Editorial

Reframing Lower GI Bleeding in India: A Tertiary Center's Insights with National Implications

Authors

  • Yogesh Harwani

    1   Noble Gastro Hospital, Ahmedabad, Gujarat, India

Funding None.
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Lower gastrointestinal bleeding (LGIB) is a clinical challenge that straddles urgency and complexity—its presentations are variable, its etiologies diverse, and its outcomes often underestimated. Despite accounting for up to one-fifth of all GI bleeds, LGIB has historically taken a backseat in terms of clinical prioritization, both in resource deployment and diagnostic urgency. The research article titled “Etiological Spectrum and Clinical Profile of Lower Gastrointestinal Bleed in a Tertiary Care Centre: A Retrospective Analysis” addresses this imbalance in academic discipline.

Conducted over 1 year at a major tertiary care referral center in northwest India, this retrospective study by Jain et al (2025)[1] in Journal of Digestive Endoscopy presents a cohort of 1,000 patients—one of the largest such Indian datasets to date—offering comprehensive demographic, clinical, colonoscopic, and etiological profiling. The findings are instructive not only for practitioners, but also for health policy makers, researchers, and educators engaged in the Indian gastroenterology landscape.

A Young Demographic with a Heavy Burden

In contrast to Western cohorts—where LGIB often predominates in older adults[2]—this study highlights a younger median presentation (mean age 48.27 years), with over two-thirds of patients under the age of 60. This age shift may be attributed to increasing urbanization, dietary transitions, and enhanced diagnostic access. With a mean age under 50, Indian LGIB patients present a decade earlier than their Western counterparts. This is not simply an epidemiological anomaly—it is a clarion call for early screening programs, public awareness campaigns, and policy-level rethinking. Waiting for bleed to happen and then performing colonoscopy is no longer acceptable in India. The bleeding does not wait, neither should we.

The male predominance (70.2%) is consistent with prior Indian data, but warrants further investigation into gender-specific risk exposures, health-seeking behavior, and diagnostic access differentials.


 

Hemorrhoids, Carcinoma, and the Spectrum in between

The most frequently identified cause of LGIB was hemorrhoids (25.9%), reaffirming their ubiquity in Indian practice. However, colorectal carcinoma (CRC) emerged as the second most common etiology suggesting increased incidence[3] [4] (18.5%) surpassing Inflammatory bowel disease,[5] [6] [7] a statistic of profound epidemiological and clinical significance.

The implications are clear: every case of hematochezia must be evaluated on its merits, with a low threshold for full colonoscopic assessment, especially in older adults. If nearly one in five LGIB patients harbor malignancy, then every missed colonoscopy is potentially a missed life. This is not academic trivia—it is clinical negligence in slow motion.

Inflammatory bowel disease (13.9%)[8]—particularly ulcerative colitis—continues to gain ground in India, adding to the global narrative of IBD transitioning from a Western to a worldwide disease. Solitary rectal ulcer syndrome (6.5%) and radiation proctitis (4.9%) reflect both diagnostic challenges and the expanding cohort of cancer survivors.

The study's identification of infectious colitis (4.1%), tubercular colitis (2.9%), and ischemic colitis (2.5%) highlights India's unique dual burden of communicable and non-communicable diseases—a pattern distinct from Western nations.


 

Colonoscopy: The Diagnostic Fulcrum

A major strength of this study is the emphasis on colonoscopy as a definitive diagnostic modality. The overall colonoscopic yield was a commendable 86.7% matching with previous studies,[9] [10] with findings including colitis (28.7%), hemorrhoids (25.9%), and ulceroproliferative growths (21.7%). The recommendation for full-length colonoscopy—rather than limited sigmoidoscopy—is both prudent and evidence-based, particularly given the rising prevalence of proximal colonic lesions. The days of casual sigmoidoscopies and blind rectal examinations must end. Full-length colonoscopic evaluation should be the minimum standard—not the exception.

The authors rightly highlight that even when overt lesions are absent, occult bleeding, anemia, or positive fecal occult blood tests warrant thorough evaluation. This reinforces colonoscopy's central role not just in diagnosis, but also in surveillance and triage for therapeutic interventions.


 

Strengths and Limitations

This study's strengths lie in its sample size, uniform methodology, and the depth of colonoscopic classification. By systematically documenting lesion types, clinical presentations, and patient demographics, it lays down a reference standard for LGIB in the Indian subcontinent.

However, the absence of enteroscopy and capsule endoscopy in patients with negative colonoscopy results is a limitation. Although understandable given infrastructural and financial constraints, this gap highlights the need for expanded tertiary care capabilities. The real bleed is happening between diagnosis and delay, between symptoms and systems.

The study also excludes pediatric patients, a group in which LGIB etiologies are entirely different. Future research targeting pediatric and adolescent populations is needed.


 

A Call to Action

The data presented in this study demand system-wide response. First, CRC must be recognized as an emerging threat; as in Western countries screening colonoscopy should be made mandatory for patients >45 if not 40 years of age in our country and opportunistic screening incorporated into LGIB workups, especially in older adults. Second, early referral pathways for hematochezia must be implemented at the primary care level to ensure timely colonoscopic evaluation. Third, institutions must strengthen diagnostic capability by investing in high-definition endoscopy, pathology support, and structured reporting systems.

Further, the Indian Society of Gastroenterology and allied bodies should consider framing national guidelines on LGIB management, incorporating region-specific data like that presented in this study.

On the research front, longitudinal studies with therapeutic endpoints—including response to endoscopic or surgical interventions—are necessary. A national LGIB registry, collecting real-time data across urban and rural centers, could transform care algorithms and inform policy.


 

Conclusion

This study is a milestone in Indian gastroenterology. It not only outlines the current landscape of LGIB but also provides a vision for future diagnostic and therapeutic paradigms. As our country continues its dual battle with infectious and lifestyle diseases, studies like this offer a roadmap that bridges clinical practice with population-level priorities.

The message is unambiguous: LGIB deserves greater attention, faster diagnosis, and broader awareness. The tools are available. The trends are visible. The onus is now on us—clinicians, institutions, and policymakers—to act with urgency, guided by data, informed by science, and committed to better outcomes.


 

 

Conflict of Interest

None declared.

Author's Contributions

Sole authorship. Editorial conceptualized, written, and reviewed by Y.H.



Address for correspondence

Yogesh Harwani, DNB
Noble Gastro Hospital
Ahmedabad, Gujarat
India   

Publication History

Article published online:
23 September 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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