Gastroenterologia Japonica Copyright 9 1991 by The Japanese Society of Gastroenterology
Vol. 26, Suppl. 3 Printed in Japan
The causes and management of lower GI bleeding: A study based on clinical observations at Hanyang University Hospital Jong Chul R H E E and Kyu Taek L E E
Department o f Internal Medicine, Hanyang University Hospital, Seoul, Korea
Introduction
Hematochezia is the term for the medical condition when bright red or maroon colored blood or bloody diarrhea comes through the rectum. It is generally acknowledged as being caused by lower GI bleeding, although it can be caused by massive and rapid upper GI bleeding of over 1,000 cc. There have been numerous clinical observations of upper GI bleeding not only overseas but also in Korea. However, no clinical statistics and observations of lower GI bleeding in Korea have been carried out before this study. The purpose of this study was to discover the causes of lower GI bleeding, paying particular attention to the mode of annual changes of lower GI bleeding and the disease groups most prevalent in Korean patients with hematochezia. The following is a brief description of the methodology and results of the study. Materials and Methods
The subject of this study was the 970 patients who were admitted to the Department of Medicine and Department of General Surgery of Hanyang University Hospital for hematochezia since January 1983 to December 1989. The causes of lower GI bleeding were diagnosed through clinical findings, laboratory findings, radiology experiments including barium studies and angiographies, radioisotope scanning, endoscopic findings or operative findings. Benign polyp was
included as one of the causes of lower GI bleeding if there was suspicious bleeding in the area surrounding the polyps and if no other incidental diseases could be found to be causing lower GI bleeding through radiology experiments and endoscopic findings. The observations were recorded according to year, incidence rate, classifications of the causing diseases, sex and age distribution, transfusion amount and treatment method. Results
1. Annual incidence rate The total number of patients with lower GI bleeding was 970, which comprised 1.6% of the total of 10,800 patients who had been admitted to the Department of Internal medicine and Department of General Surgery of Hanyang University Hospital during the study period. The percentage of patients with lower GI bleeding to total patients was 1.3% in 1983, 1.8% in 1986 and 1.9% in 1989. Thus, there were no statistically significant annual increases in the occurrence of lower GI bleeding from 1983 to 1989 (Table 1). 2. Classification of causes of lower GI bleeding The causes of lower GI bleeding in the 970 patients were benign anal diseases in 653 cases (65.5%), of which hemorrhoids was the cause of 586 cases (60.4%), anal fissure 47 eases (4%) and anal fistula 2 cases (0.2%), and malignant neoplasm in 205 cases (21.1%), of which rectal cancer
Gastroenterol Jpn 1991:26(Suppl3)101-106 Address for correspondence: Jong Chul Rhee, M.D., Associate Professor of Medicine, Hanyang University Hospital, San-17, HaengdangDong, Sungdong-Ku, Seoul, Korea.
102
Vol. 26, Suppl. 3
J.C. R h e e et al.
Table 1 Annual distribution of lower GI bleeding
Lower GI bleeding patients No. of medical & surgical inpatients %
'83
'84
'85
'86
'87
'88
'89
Total
124 9229
104 9724
124 8388
145 8256
172 8025
141 8684
160 8485
970 60800
1.3%
1.1 %
1.5%
1.8%
2.1%
1.6%
1.9%
1.6%
Table 2 The incidence of lower GI bleeding ('83-89)
Hemorrhoid & anal fissure Malignant neoplasm Benign neoplasm Ulcerative colitis Infectious colitis Ischemic colitis Radiation colitis Diverticulosis Miscellaneus Total
'83
'84
'85
'86
'87
'88
'89
85 20 8 1 8 1 1
71 19 5 2 4 1 2
83 27 5 2 3 2 1 1
97 28 5 5 3 3 2
116 36 8 6 2 2 2
86 33 4 8 2 4 2 2
97 42 6 8
172
141
160
4 3
2 124
104
124
was the cause of 164 cases (16.9%), sigmoid colon cancer 32 cases (3.3%), and anal cancer (0.9%). Other causes of lower GI bleeding were: benign neoplasm in 41 cases (4.2%), of which rectal polyps was the cause of 19 cases, and polyps 19 cases, multiple colonic polyposis 2 cases and sigmoid colonic polyp 1 case; ulcerative colitis in 32 cases (3.3%); infectious colitis in 22 cases (2.3%); and ischemic colitis in 17 cases (1.8%). Less c o m m o n causes of lower GI bleeding were: radiation colitis in 13 cases (1.3%); diverticulosis in 3 cases (0.2%); and rectal mucosal laceration and rectal ulcer of u n k n o w n causes in 1 case each (Table 2).
3. Mode of annual changes The annual incidence rate of lower GI bleeding remained a constant 1.6% of the total admitted patients during the period of this study. However, there have been some changes in the frequency of the disease groups responsible for lower GI bleeding, with the exception of hemorrhoids and anal fissure whose incidence rate remained the same. For example, malignant neoplasm (rectal cancer, sigmoid colon cancer and anal cancer) showed an increasing trend from 20 cases in 1983 to 42 cases
145
Total 635 205 41 32 22 17 13 3 2
(65,5%) (21,1%) (4.2%) (3.3%) (2.3%) (1.8%) (1.3%) (0.3%) (0.2%)
970
(100%)
in 1989. Ulcerative colitis also showed an increasing trend from 1 case in 1983 to 8 cases in 1989, while cases of infectious colitis decreased from 8 cases in 1983 to none in 1989. Ischemic colitis showed an increase from 1 case in 1983 to 4 cases in 1989, but no decisive conclusion can be drawn about the trend of ischemic colitis from this data alone (Table 2).
4. Sexual predominance Male patients comprised 505 cases (52.1%) and female patients comprised 465 cases (47.9%), making the male to female ratio 1.09:1. Thus, there was no particular sexual predominance related to lower GI bleeding. However, there were some differences in the incidence rate of some diseases according to sex. For example, ulcerative colitis occurred more frequently in females with 11 male patients to 21 female patients. In radiation colitis, the female predominance was remarkably greater with 1 male patient to 12 female patients. The higher incidence rate of radiation colitis in females is believed to be caused by the greater proportion of female cervical cancer patients who are treated with radiology.
July 1991
Clinical observations." Causes and management of lower GI bleeding
103
Table 3 Age distribution Hemorrhoid & anal fissure
Malignant neoplasm
Benign neoplasm
Ulcerative colitis
Infectious colitis
10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89
9 141 190 136 62 69 23 5
1 12 18 45 62 46 20 1
2 4 7 17 5 4 2
1 1 6 10 10 3
1 4 3 5 3 3 3
1 1 1 4 9
1 6 4 2
Total
635
205
41
22
17
13
Total (%)
1
Medical & conservative Tx
Ratio
543
101
5.3:1
38 192 3 1 2 3 1
3 13
12.7:1 14.8:1
1 15 29 21 13 196 (20.2%)
32
patients with ulcerative colitis (21.9%) and radiation colitis (23.1%) required transfusions.
Operation
774 (79.8%)
Radiation colitis
1
Table 4 Management of lower GI bleeding
Hemorrhoid & anal fissure Benign neoplasm Malignant neoplasm Diverticulosis Miscellaneus Ischemic colitis Ulcerative colitis Infectious colitis Radiation colitis
Ischemic colitis
1:7.5 1:9.7 1:21 4.0:1
5. Age distribution There are definite correlations between age and the disease groups which cause lower GI bleeding. For example, hemorrhoid and anal fissure developed mostly in the 30s age group, while benign neoplasm developed mostly in patients who were in their 40s. Ulcerative colitis developed mostly in those in their 40s and 50s, while malignant neoplasm generally developed in people in their 50s. Ischemic colitis was the cause of lower GI bleeding mainly in the 60s age group. On the other hand, infectious colitis was found in all age groups (Table 3). 6. Transfusion amount A total of 105 cases (10.8%) of the 970 patients admitted to the hospital needed transfusions owing to severe anemia or hemodynamic changes caused by lower GI bleeding. In particular, more
7. Treatment method In the treatment of lower GI bleeding, 774 cases (79.8%) underwent surgical operations, while 196 cases (20.2%) only received medical and conservative treatments. Many of the malignant neoplasm and benign neoplasm patients had to undergo surgical operations, while patients with ischemic colitis, ulcerative colitis, infectious colitis and radiation colitis received only medical treatments (Table 4). For the treatment of benign neoplasm (rectal polyp, anal polyp, sigmoid coIonic polyp, multiple colonic polyposis), 17 cases (41.5%) received surgical operations, 21 cases (51.2%) underwent polypectomies, and 3 cases (7.3%) were treated for followup observations. Discussion
GI bleeding requires quick and precise diagnosis as it often occurs in emergency room situations. The 10% mortality rate associated with lower GI bleeding has not significantly decreased in the past 20 years despite the development of anesthetic and diagnostic techniques such as colonoscopy, angiography, and radionuclide scan 1-3. One reason why the mortality rate has remained high is that in the advanced countries from the mid 1950s to the late 1960s the major cause of rapid massive lower GI bleeding or recurrent lower GI bleeding was diverticulosis, which was believed to be located in the left colon. Thus, an
104
J.C. R h e e et al.
operation for a left side colectomy was carried out. Despite this operation, however, 50% of the patients continued to show recurrent bleeding and the mortality rate not only did not decrease but shot up to 20%. Since the 1960s, it has been discovered that the bleeding occurred in the right side colon and surgeons have accordingly carried out curative subtotal colectomies. As a result, the recurrent bleeding rate has dropped and the mortality rate has also returned to 10% 4,5. Currently, newly developed diagnostic methods can locate the precise bleeding region so that surgeons can do segmental resections. Recurrent bleeding after an operation is generally negligible and the mortality rate owing to massive bleeding has decreased to less than 5% 6 . In most cases of hemorrhoid bleeding, a small amount of bright red blood was found on hard stools or stained on toilet paper; however, occasionally, massive bleeding also occurred. Patients were given seat baths and medical treatment with a suppository or stool softner. If bleeding continued or there were frequent recurrences despite the medical treatment, a surgical operation was undertaken 7. In this study, the n u m b e r of patients who needed transfusions of the total hemorrhoid patients admitted to the hospital was 8.8%. Thus, many more hospitalized patients required surgical operations compared to the outpatients. This is due to the fact that outpatients who were given medical treatments had light symptoms, whereas admitted patients were those not responding to medical treatments and were experiencing frequent recurrences and massive blood loss. In general, however, lower GI bleeding caused by hemorrhoids can easily be diagnosed by digital rectal and proctoscopic exams along with an examination of the patients' medical history. Balint, et. al., reported that malignant neoplasm, especially sigmoid colon cancer and diverticulosis, was responsible for 31% of lower GI bleeding 8. Malignant neoplasm is known to cause chronic or occult blood loss rather than massive blood loss. It can be easily diagnosed through a colonoscopy exam or colonic barium study 9. In the United States, colon cancer is the second
Vol. 26, Suppl. 3
largest cause of death due to cancer after lung cancer. The occurrence rate of colon cancer is increasing in Korea and Japan due to the trend toward a more westernized diet characterized by large amounts of animal fat and less fiber content. In the West, diverticulosis is a very popular disease found in 10-50% of the over 50s age group. But in most cases, there are no subjective symptoms and bleeding caused by diverticulosis is rare. However, despite the lower incidence of bleeding, the high occurrence rate of diverticulosis in the population in general has made it a major longstanding cause of lower GI bleeding 11"12. In Korea and Asia in general, the incidence rate is much lower and cases of bleeding are very rare. Although the precise reason for this difference is unknown, it is believed to be caused by the different dietary habits, particularly with respect to the fiber content 13. Ulcerative colitis is chronic inflammatory disease that occurs in the left colon or rectum and the main symptoms are rectal bleeding and bloody diarrhea. The occurrence rate of ulcerative colitis is reported to be 1.8 to 15.8 per 100,000 population. Ulcerative colitis is a c o m m o n problem in the West and its occurrence rate has been steadily increasing ~4'~5. In the past, this disease was believed to mainly occur in the West, but recently the occurrence rate of the disease has been increasing in Asia, in such countries as Japan, india and Thailand. As shown by this study, this is also the case in Korea. As lower GI bleeding by infectious colitis is rare in the West, it has been eliminated as one of the causes of lower GI bleeding 16. However, it is still a serious problem in underdeveloped countries. This study found a total of 22 cases of infectious colitis, in the form of dysentery, amebiasis, and typhoid fever. Especially noteworthy were the two cases of intestinal Needing involving a typhoid complication which required a transfusion of over 5,000 ml due to massive bleeding and hypotension. In these two cases, the bleeding sites were confirmed by emergency angiography and right hemi-colectomies were carried out. Infectious colitis in Korea has significantly decreased through the appropriate administration of anti-
July 1991
Clinical observations: Causes and management of lower GI bleeding
biotics and development of preventive medicine. Ischematic colitis is recognized as developing mostly in the over-50 age group with artherosclerotic vascular diseases. The severity of the cases is related to the progressive speed of the ischemia. In these cases angiography and colonoscopy are helpful in diagnosing the disease L8'19. Patients in these cases had mild symptoms of abdominal pain and rectal bleeding which were treated through supportive measures. However, there were some cases reported in which an operation was required because of massive bleeding 2~ Radiation colitis occurred mostly in patient with intrapelvic malignant neoplasm who underwent radiation therapy. The diseases can develop at the beginning or end of radiation therapy, or even months or years later when the radiation amount exceeds Gy 21'22. In this study, most of the cases of rectal bleeding by radiation colitis were cervical cancer patients who received radiation therapy 23. Angiodysplasia appeared from the late 1970s, predominantly in elderly age groups in the West 24'25. It occurred mostly in the appendix and ascending colon, sometimes accompanied by aortic stenosis 26. The disease causes morphological abnormalities of the microcirculation system as it spreads into the small arteries, capillaries or veins of diameters of 5mm or less. Occassionally, it can have multiple developments, owing to degeneration caused by old age 26. To diagnose this disease, biopsies 27 via a colonoscopy and angiography are helpful. Although in this study there were no cases of angiodysplasia, two such cases have been diagnosed recently. It is probable that there were cases of bleeding by angiodysplasia among the lower G I bleeding patients also in the past but were not diagnosed as such due to the lack of diagnostic techniques and knowledge of the disease. However, with more information on the disease and advanced diagnostic techniques, angiodysplasia can be more easily diagnosed today. Massive bleeding is rare in lower G! bleeding. Noer, et. al., reported that 10% of the lower GI bleeding patients required transfusions 29. The need for transfusions, however, may differ ac-
105
cording to the disease group. In this study, 10.8% of the lower GI bleeding patients who were admitted to the hospital needed transfusions. The most important factor in the treatment of lower GI bleeding is not finding the bleeding site. It is more important to accurately judge the amount of the bleeding and be able to classify it as occult, minor overt, and major overt, and prepare for the next treatment procedure. In the case of occult and minor bleeding, diagnosis is possible by angiography when the usual diagnostic methods do not work and the condition can be easily improved through supportive treatments. On the other hand, in the case of major overt bleeding, the patient has to undergo emergency operation after locating the bleeding site by emergency angiography 3~
Summary During the period of the study, lower GI bleeding patients comprised a constant 1.6% of the total admitted patients at Hanyang University Hospital annually. There were no statistically significant changes according to year. The 970 cases were classified as follows: hemorrhoid and anal fissure 65.5%, malignant neoplasm 21.1% (rectal cancer 16.9%, sigmoid colon cancer 3.3%, anal cancer 0.9%), benign neoplasm 4.2%, ulcerative colitis 3.3%, infectious colitis 2.3%, ischemic colitis 1.8%, radiation colitis 1.3%, diverticulosis 0.3%, and others 0.2%. Ulcerative colitis and rectosigmoid cancer showed increasing trends, while other disease groups showed no change in the occurrence rate. Hemorrhoid and anal fissure developed mostly in the 30s age group, benign polyp and ulcerative colitis in the 40s age group, malignant neoplasm in the 50s age group, and ischemic colitis and radiation colitis in the 60s age group. There was no sexual predominance of lower GI bleeding. About 10% of the patients admitted to the hospital needed transfusions, particularly patients with ulcerative colitis (21.9%) and radiation colitis (23.1%). 20.2% of the patients improved with supportive measures and medical treatment and 79.8% underwent surgical operation. In particular, 51.2% of the patients with
106
J.C. Rhee et al.
benign neoplasm underwent polypectomies. 15.
References 1. Schiller KFR, Truelove SC, Williams DG: Hematemesis and melena with special refererence to factors influencing the outcome. Br Med J 1970;2:7 2. Allan RN, Dykes PW: A study of the factors influencing mortality rates from gastrointestinal hemorrhage. QJ Med 1976;45: 533 3. Dronfield MW, Atkinson M, Langman MJS: Effect of different operation policies on mortality from bleeding peptic ulcer. Lancet 1979;1:1126 4. McGuire HH, Haynes BW: Massive hemorrhage from diverticulosis of colon. Ann Surg 1972;175:847 5. Drapanas T, Pennington DG, Kappelman M, et al: Emergency subtotal colectomy: preferred approach to management of massive bleeding diverticular disease. Ann Surg 1973;177:519 6. Wright HK, Peliccia O, Higgins EF, et al: Controlled semielective, segmental resection for massive colonic hemorrhage, Am J Surg 1980;139:535 7. Norman DQ, Newton R, Nicholas GV: Management of hemorrhoidal disease: an effective, safe and painless outpatient approach using D.C. Current. Gastrointest Endosc 1987;33:176 8. Balint JA, Sarfeh IJ, Fried MB: Gastrointestinal bleeding. Diagnosis and management. Clinical Gastroenterology Monograph Series. Wiley, New York 1977 9. Jensen J, Kewenter J, Haglind E, et al: Diagnostic accuracy of double-contrast enema and rectosigmoido-scopy in connection with fecal occult blood testing for detection of rectosigmoid neoplasms. Br J Surg 1986;73:961 10. Rozen P, Hellerstein S, Horwitz C: The low incidence of colorectal cancer in a "high risk" population. Its correlation with dietary habits. Cancer 1981;48:2692 11. Brian JE, Stair JM: Non-colonic diverticular disease. Surg Gynecol Obstet 1985;161 : 189 12. Thompson WG, Patel DG: Clinical picture of diverticular disease of the colon. Clinics Gastroenterol 1986;15:903 13. Almy TP, Howell DA: Diverticular disease of the colon. N Engl J Med 1980;302:324 14. Monk M, Mendeloff AI, Siegel CI, et al: An epidemiological study of ulcerative colitis and regional enteritis among adults in
16.
17.
18.
19. 20.
21.
22. 23. 24.
25. 26.
27. 28. 29. 30.
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Baltimore. I. Hipital incidence and prevalence, 1960-1963 Gastroenterology 1967;53:198 Binder V, Both H, Hansen PI, et al: Incidence and prevalence of ulcerative colitis and Crohn's disease in the County of Copenhagen, 1962-1978. Gastroenterology 1982;83:563 Sleisenger MH, Fordtran JS: Gastrointestinal bleeding in Gastrointestinal Disease: Pathophysiology. Diagnosis, Management. 4th Ed. WB Saunders company, Philadelphia 1989;401 Wig JD, Malik AK, Khanna SK, et al: Massive lower gastrointestinal bleeding in patients with typhoid fever. Am J Gastroenterol 1981;75:445 Ottinger LW, Darling RC, Nathan MJ, et al: Left colon ischemia complicating aorto-iliac reconstruction. Causes, diagnosis, management and prevention. Arch Surg 1972;105:841 De Dombal FT, Fletcher DM, Harris RS: Early diagnosis of ischemic colitis. Gut 1969;10:131 Chou YH, Hsu SC, Wang CY, et al: Ischemic colitis as a cause of massive lower gastrointestinal bleeding and peritonitis. Report of five cases. Dis Colon Rectum 1989;32:1065 Novak JM, Collins JT, Donowitz M, et al: Effects of radiation on the human gastrointestinal tract. J Clin Gastroenterol 1979; 1:9, Potish RA: Importance of predisposing factors in the development of enteric damage. Am J Clin Oncol 1982;5:189, Palmer JA, Bush RS: Radiation injuries of the bowel associated with carcinoma of the cervix. Surgery 1976;80:458 Boley SJ, Sammartano R, Adams A, et al: On the nature and etiology of vascular ectasias of colon. Gastroenterology 1977;72: 650 Howard OM, Buchana JD, Hunt RH: Angiodysplasia of the colon: Lancet 1982;2:16 Greenstein RJ, McElhinney AJ, Reuben D, ct al: Colonic vascular ectasias and aortic stenosis: coincidence or causal relationship? Am J Surg 1986;151:347 Allison D J, Hemingway AP, Cunningham DA: Angiography in gastrointestinal bleeding. Lancet 1982;2:30 Howard OM, Buchana JD, Hung RH: Angiodysplasia. Lancet 1981:2:1340 Noer RJ: Hemorrhage as a complication of diverticulitis. Ann Surg 1955;141:674 Lawrence MA, Hooks VH 3rd, Bowden TA Jr: Lower gastrointestinal bleeding. A systematic approach to classification and management. Postgrad Med 1989;85:89
Vol. 26, Suppl. 3 Printed in Japan
The causes and management of lower GI bleeding: A study based on clinical observations at Hanyang University Hospital Jong Chul R H E E and Kyu Taek L E E
Department o f Internal Medicine, Hanyang University Hospital, Seoul, Korea
Introduction
Hematochezia is the term for the medical condition when bright red or maroon colored blood or bloody diarrhea comes through the rectum. It is generally acknowledged as being caused by lower GI bleeding, although it can be caused by massive and rapid upper GI bleeding of over 1,000 cc. There have been numerous clinical observations of upper GI bleeding not only overseas but also in Korea. However, no clinical statistics and observations of lower GI bleeding in Korea have been carried out before this study. The purpose of this study was to discover the causes of lower GI bleeding, paying particular attention to the mode of annual changes of lower GI bleeding and the disease groups most prevalent in Korean patients with hematochezia. The following is a brief description of the methodology and results of the study. Materials and Methods
The subject of this study was the 970 patients who were admitted to the Department of Medicine and Department of General Surgery of Hanyang University Hospital for hematochezia since January 1983 to December 1989. The causes of lower GI bleeding were diagnosed through clinical findings, laboratory findings, radiology experiments including barium studies and angiographies, radioisotope scanning, endoscopic findings or operative findings. Benign polyp was
included as one of the causes of lower GI bleeding if there was suspicious bleeding in the area surrounding the polyps and if no other incidental diseases could be found to be causing lower GI bleeding through radiology experiments and endoscopic findings. The observations were recorded according to year, incidence rate, classifications of the causing diseases, sex and age distribution, transfusion amount and treatment method. Results
1. Annual incidence rate The total number of patients with lower GI bleeding was 970, which comprised 1.6% of the total of 10,800 patients who had been admitted to the Department of Internal medicine and Department of General Surgery of Hanyang University Hospital during the study period. The percentage of patients with lower GI bleeding to total patients was 1.3% in 1983, 1.8% in 1986 and 1.9% in 1989. Thus, there were no statistically significant annual increases in the occurrence of lower GI bleeding from 1983 to 1989 (Table 1). 2. Classification of causes of lower GI bleeding The causes of lower GI bleeding in the 970 patients were benign anal diseases in 653 cases (65.5%), of which hemorrhoids was the cause of 586 cases (60.4%), anal fissure 47 eases (4%) and anal fistula 2 cases (0.2%), and malignant neoplasm in 205 cases (21.1%), of which rectal cancer
Gastroenterol Jpn 1991:26(Suppl3)101-106 Address for correspondence: Jong Chul Rhee, M.D., Associate Professor of Medicine, Hanyang University Hospital, San-17, HaengdangDong, Sungdong-Ku, Seoul, Korea.
102
Vol. 26, Suppl. 3
J.C. R h e e et al.
Table 1 Annual distribution of lower GI bleeding
Lower GI bleeding patients No. of medical & surgical inpatients %
'83
'84
'85
'86
'87
'88
'89
Total
124 9229
104 9724
124 8388
145 8256
172 8025
141 8684
160 8485
970 60800
1.3%
1.1 %
1.5%
1.8%
2.1%
1.6%
1.9%
1.6%
Table 2 The incidence of lower GI bleeding ('83-89)
Hemorrhoid & anal fissure Malignant neoplasm Benign neoplasm Ulcerative colitis Infectious colitis Ischemic colitis Radiation colitis Diverticulosis Miscellaneus Total
'83
'84
'85
'86
'87
'88
'89
85 20 8 1 8 1 1
71 19 5 2 4 1 2
83 27 5 2 3 2 1 1
97 28 5 5 3 3 2
116 36 8 6 2 2 2
86 33 4 8 2 4 2 2
97 42 6 8
172
141
160
4 3
2 124
104
124
was the cause of 164 cases (16.9%), sigmoid colon cancer 32 cases (3.3%), and anal cancer (0.9%). Other causes of lower GI bleeding were: benign neoplasm in 41 cases (4.2%), of which rectal polyps was the cause of 19 cases, and polyps 19 cases, multiple colonic polyposis 2 cases and sigmoid colonic polyp 1 case; ulcerative colitis in 32 cases (3.3%); infectious colitis in 22 cases (2.3%); and ischemic colitis in 17 cases (1.8%). Less c o m m o n causes of lower GI bleeding were: radiation colitis in 13 cases (1.3%); diverticulosis in 3 cases (0.2%); and rectal mucosal laceration and rectal ulcer of u n k n o w n causes in 1 case each (Table 2).
3. Mode of annual changes The annual incidence rate of lower GI bleeding remained a constant 1.6% of the total admitted patients during the period of this study. However, there have been some changes in the frequency of the disease groups responsible for lower GI bleeding, with the exception of hemorrhoids and anal fissure whose incidence rate remained the same. For example, malignant neoplasm (rectal cancer, sigmoid colon cancer and anal cancer) showed an increasing trend from 20 cases in 1983 to 42 cases
145
Total 635 205 41 32 22 17 13 3 2
(65,5%) (21,1%) (4.2%) (3.3%) (2.3%) (1.8%) (1.3%) (0.3%) (0.2%)
970
(100%)
in 1989. Ulcerative colitis also showed an increasing trend from 1 case in 1983 to 8 cases in 1989, while cases of infectious colitis decreased from 8 cases in 1983 to none in 1989. Ischemic colitis showed an increase from 1 case in 1983 to 4 cases in 1989, but no decisive conclusion can be drawn about the trend of ischemic colitis from this data alone (Table 2).
4. Sexual predominance Male patients comprised 505 cases (52.1%) and female patients comprised 465 cases (47.9%), making the male to female ratio 1.09:1. Thus, there was no particular sexual predominance related to lower GI bleeding. However, there were some differences in the incidence rate of some diseases according to sex. For example, ulcerative colitis occurred more frequently in females with 11 male patients to 21 female patients. In radiation colitis, the female predominance was remarkably greater with 1 male patient to 12 female patients. The higher incidence rate of radiation colitis in females is believed to be caused by the greater proportion of female cervical cancer patients who are treated with radiology.
July 1991
Clinical observations." Causes and management of lower GI bleeding
103
Table 3 Age distribution Hemorrhoid & anal fissure
Malignant neoplasm
Benign neoplasm
Ulcerative colitis
Infectious colitis
10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89
9 141 190 136 62 69 23 5
1 12 18 45 62 46 20 1
2 4 7 17 5 4 2
1 1 6 10 10 3
1 4 3 5 3 3 3
1 1 1 4 9
1 6 4 2
Total
635
205
41
22
17
13
Total (%)
1
Medical & conservative Tx
Ratio
543
101
5.3:1
38 192 3 1 2 3 1
3 13
12.7:1 14.8:1
1 15 29 21 13 196 (20.2%)
32
patients with ulcerative colitis (21.9%) and radiation colitis (23.1%) required transfusions.
Operation
774 (79.8%)
Radiation colitis
1
Table 4 Management of lower GI bleeding
Hemorrhoid & anal fissure Benign neoplasm Malignant neoplasm Diverticulosis Miscellaneus Ischemic colitis Ulcerative colitis Infectious colitis Radiation colitis
Ischemic colitis
1:7.5 1:9.7 1:21 4.0:1
5. Age distribution There are definite correlations between age and the disease groups which cause lower GI bleeding. For example, hemorrhoid and anal fissure developed mostly in the 30s age group, while benign neoplasm developed mostly in patients who were in their 40s. Ulcerative colitis developed mostly in those in their 40s and 50s, while malignant neoplasm generally developed in people in their 50s. Ischemic colitis was the cause of lower GI bleeding mainly in the 60s age group. On the other hand, infectious colitis was found in all age groups (Table 3). 6. Transfusion amount A total of 105 cases (10.8%) of the 970 patients admitted to the hospital needed transfusions owing to severe anemia or hemodynamic changes caused by lower GI bleeding. In particular, more
7. Treatment method In the treatment of lower GI bleeding, 774 cases (79.8%) underwent surgical operations, while 196 cases (20.2%) only received medical and conservative treatments. Many of the malignant neoplasm and benign neoplasm patients had to undergo surgical operations, while patients with ischemic colitis, ulcerative colitis, infectious colitis and radiation colitis received only medical treatments (Table 4). For the treatment of benign neoplasm (rectal polyp, anal polyp, sigmoid coIonic polyp, multiple colonic polyposis), 17 cases (41.5%) received surgical operations, 21 cases (51.2%) underwent polypectomies, and 3 cases (7.3%) were treated for followup observations. Discussion
GI bleeding requires quick and precise diagnosis as it often occurs in emergency room situations. The 10% mortality rate associated with lower GI bleeding has not significantly decreased in the past 20 years despite the development of anesthetic and diagnostic techniques such as colonoscopy, angiography, and radionuclide scan 1-3. One reason why the mortality rate has remained high is that in the advanced countries from the mid 1950s to the late 1960s the major cause of rapid massive lower GI bleeding or recurrent lower GI bleeding was diverticulosis, which was believed to be located in the left colon. Thus, an
104
J.C. R h e e et al.
operation for a left side colectomy was carried out. Despite this operation, however, 50% of the patients continued to show recurrent bleeding and the mortality rate not only did not decrease but shot up to 20%. Since the 1960s, it has been discovered that the bleeding occurred in the right side colon and surgeons have accordingly carried out curative subtotal colectomies. As a result, the recurrent bleeding rate has dropped and the mortality rate has also returned to 10% 4,5. Currently, newly developed diagnostic methods can locate the precise bleeding region so that surgeons can do segmental resections. Recurrent bleeding after an operation is generally negligible and the mortality rate owing to massive bleeding has decreased to less than 5% 6 . In most cases of hemorrhoid bleeding, a small amount of bright red blood was found on hard stools or stained on toilet paper; however, occasionally, massive bleeding also occurred. Patients were given seat baths and medical treatment with a suppository or stool softner. If bleeding continued or there were frequent recurrences despite the medical treatment, a surgical operation was undertaken 7. In this study, the n u m b e r of patients who needed transfusions of the total hemorrhoid patients admitted to the hospital was 8.8%. Thus, many more hospitalized patients required surgical operations compared to the outpatients. This is due to the fact that outpatients who were given medical treatments had light symptoms, whereas admitted patients were those not responding to medical treatments and were experiencing frequent recurrences and massive blood loss. In general, however, lower GI bleeding caused by hemorrhoids can easily be diagnosed by digital rectal and proctoscopic exams along with an examination of the patients' medical history. Balint, et. al., reported that malignant neoplasm, especially sigmoid colon cancer and diverticulosis, was responsible for 31% of lower GI bleeding 8. Malignant neoplasm is known to cause chronic or occult blood loss rather than massive blood loss. It can be easily diagnosed through a colonoscopy exam or colonic barium study 9. In the United States, colon cancer is the second
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largest cause of death due to cancer after lung cancer. The occurrence rate of colon cancer is increasing in Korea and Japan due to the trend toward a more westernized diet characterized by large amounts of animal fat and less fiber content. In the West, diverticulosis is a very popular disease found in 10-50% of the over 50s age group. But in most cases, there are no subjective symptoms and bleeding caused by diverticulosis is rare. However, despite the lower incidence of bleeding, the high occurrence rate of diverticulosis in the population in general has made it a major longstanding cause of lower GI bleeding 11"12. In Korea and Asia in general, the incidence rate is much lower and cases of bleeding are very rare. Although the precise reason for this difference is unknown, it is believed to be caused by the different dietary habits, particularly with respect to the fiber content 13. Ulcerative colitis is chronic inflammatory disease that occurs in the left colon or rectum and the main symptoms are rectal bleeding and bloody diarrhea. The occurrence rate of ulcerative colitis is reported to be 1.8 to 15.8 per 100,000 population. Ulcerative colitis is a c o m m o n problem in the West and its occurrence rate has been steadily increasing ~4'~5. In the past, this disease was believed to mainly occur in the West, but recently the occurrence rate of the disease has been increasing in Asia, in such countries as Japan, india and Thailand. As shown by this study, this is also the case in Korea. As lower GI bleeding by infectious colitis is rare in the West, it has been eliminated as one of the causes of lower GI bleeding 16. However, it is still a serious problem in underdeveloped countries. This study found a total of 22 cases of infectious colitis, in the form of dysentery, amebiasis, and typhoid fever. Especially noteworthy were the two cases of intestinal Needing involving a typhoid complication which required a transfusion of over 5,000 ml due to massive bleeding and hypotension. In these two cases, the bleeding sites were confirmed by emergency angiography and right hemi-colectomies were carried out. Infectious colitis in Korea has significantly decreased through the appropriate administration of anti-
July 1991
Clinical observations: Causes and management of lower GI bleeding
biotics and development of preventive medicine. Ischematic colitis is recognized as developing mostly in the over-50 age group with artherosclerotic vascular diseases. The severity of the cases is related to the progressive speed of the ischemia. In these cases angiography and colonoscopy are helpful in diagnosing the disease L8'19. Patients in these cases had mild symptoms of abdominal pain and rectal bleeding which were treated through supportive measures. However, there were some cases reported in which an operation was required because of massive bleeding 2~ Radiation colitis occurred mostly in patient with intrapelvic malignant neoplasm who underwent radiation therapy. The diseases can develop at the beginning or end of radiation therapy, or even months or years later when the radiation amount exceeds Gy 21'22. In this study, most of the cases of rectal bleeding by radiation colitis were cervical cancer patients who received radiation therapy 23. Angiodysplasia appeared from the late 1970s, predominantly in elderly age groups in the West 24'25. It occurred mostly in the appendix and ascending colon, sometimes accompanied by aortic stenosis 26. The disease causes morphological abnormalities of the microcirculation system as it spreads into the small arteries, capillaries or veins of diameters of 5mm or less. Occassionally, it can have multiple developments, owing to degeneration caused by old age 26. To diagnose this disease, biopsies 27 via a colonoscopy and angiography are helpful. Although in this study there were no cases of angiodysplasia, two such cases have been diagnosed recently. It is probable that there were cases of bleeding by angiodysplasia among the lower G I bleeding patients also in the past but were not diagnosed as such due to the lack of diagnostic techniques and knowledge of the disease. However, with more information on the disease and advanced diagnostic techniques, angiodysplasia can be more easily diagnosed today. Massive bleeding is rare in lower G! bleeding. Noer, et. al., reported that 10% of the lower GI bleeding patients required transfusions 29. The need for transfusions, however, may differ ac-
105
cording to the disease group. In this study, 10.8% of the lower GI bleeding patients who were admitted to the hospital needed transfusions. The most important factor in the treatment of lower GI bleeding is not finding the bleeding site. It is more important to accurately judge the amount of the bleeding and be able to classify it as occult, minor overt, and major overt, and prepare for the next treatment procedure. In the case of occult and minor bleeding, diagnosis is possible by angiography when the usual diagnostic methods do not work and the condition can be easily improved through supportive treatments. On the other hand, in the case of major overt bleeding, the patient has to undergo emergency operation after locating the bleeding site by emergency angiography 3~
Summary During the period of the study, lower GI bleeding patients comprised a constant 1.6% of the total admitted patients at Hanyang University Hospital annually. There were no statistically significant changes according to year. The 970 cases were classified as follows: hemorrhoid and anal fissure 65.5%, malignant neoplasm 21.1% (rectal cancer 16.9%, sigmoid colon cancer 3.3%, anal cancer 0.9%), benign neoplasm 4.2%, ulcerative colitis 3.3%, infectious colitis 2.3%, ischemic colitis 1.8%, radiation colitis 1.3%, diverticulosis 0.3%, and others 0.2%. Ulcerative colitis and rectosigmoid cancer showed increasing trends, while other disease groups showed no change in the occurrence rate. Hemorrhoid and anal fissure developed mostly in the 30s age group, benign polyp and ulcerative colitis in the 40s age group, malignant neoplasm in the 50s age group, and ischemic colitis and radiation colitis in the 60s age group. There was no sexual predominance of lower GI bleeding. About 10% of the patients admitted to the hospital needed transfusions, particularly patients with ulcerative colitis (21.9%) and radiation colitis (23.1%). 20.2% of the patients improved with supportive measures and medical treatment and 79.8% underwent surgical operation. In particular, 51.2% of the patients with
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benign neoplasm underwent polypectomies. 15.
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