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
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
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
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
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.