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Practice Rational Imaging

Acute lower gastrointestinal haemorrhage

BMJ 2009; 339 doi: (Published 17 November 2009) Cite this as: BMJ 2009;339:b4156
  1. Andrew J Edwards, radiologist,
  2. Giles F Maskell, radiologist
  1. 1Royal Cornwall Hospital, Truro TR1 3LJ
  1. Correspondence to: G F Maskell giles.maskell{at}

    In most patients acute lower gastrointestinal bleeding resolves with conservative management, but when bleeding is especially severe, more invasive investigations and treatment may be needed

    Learning points

    • In most patients acute lower gastrointestinal bleeding resolves with conservative management

    • In patients with haemodynamic instability accurate identification of the source of bleeding is required to guide therapeutic intervention

    • Multidetector row computed tomography angiography is emerging as a fast, accurate, and non-invasive method of identifying the source of haemorrhage

    • Patients with massive or recurrent lower gastrointestinal bleeding are often elderly with substantial comorbidity. Accurate localisation can reduce mortality, although this remains high in this group

    An 81 year old woman presented to hospital with a 12 hour history of passing copious blood per rectum. She gave a history of ischaemic heart disease with previous coronary stent insertions and chronic obstructive pulmonary disease. She was taking regular aspirin but was not taking an anticoagulant. She had no other relevant medical history.

    On examination she was pale with cool extremities. Her pulse was thready (very fine and scarcely perceptible) at 100 beats/min, and her blood pressure was 100/76 mm Hg. Examination of the abdomen was normal but active rectal bleeding was noted.

    What is the next investigation?

    Although the history is highly suggestive of bleeding from the lower gastrointestinal tract, about 10-15% of patients presenting in this way are bleeding from a source in the upper gastrointestinal tract.1 Upper gastrointestinal endoscopy should therefore be considered in the first …

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