Massive lower intestinal bleeding--a decade of experience.

BACKGROUND: Lower gastrointestinal bleeding is defined as hemorrhage orginating distal to the ligament of Treitz. Its diagnosis is difficult, often requiring endoscopy, angiography and isotope scans. METHODS: All patients with massive lower gastrointestinal bleeding seen in three gastroenterology centers of Armed Forces during an 11 year period between 1988 and 1999 were retrospectively analysed. RESULTS: A total of 91 patients with massive lower gastro intestinal bleeding were seen during 11 years. The mean age of the patients was 38.9 years and 64 were males. Aetiological diagnosis was: Non-specific ulcers--11, Ileal tuberculosis--8, NSAID enteropathy--8, Enteric fever--7, Meckel's diverticulum--7, Polyps--6, Ulcerative colitis--5, Carcinoma colon--5, Colonic diverticulosis--5, No cause found--5, Polyposis coli--5, Jejunal diverticulae--3, Angiodysplasia colon--3, Radiation colitis--3, Ischaemic colitis--3, Ileal tumor--2, Ileal angiodysplasia--2, Intestinal Lymphoma--2, Bechet's syndrome--1. Bleeding stopped on conservative therapy in 18 patients (including 5 where no diagnosis could be made). Diagnosis was made in 36 patients on fiber-optic colonoscopy done during active bleeding. Remaining patients were subjected to emergency laparotomy and diagnosis was obvious on inspection of abdominal contents in 25 cases. The diagnosis was finally made in remaining 12 cases by intraoperative endoscopic examination through an ileotomy. Four patients died, only one of them due to rebleed after surgery from an additional lesion. CONCLUSIONS: Compared with experience in Western countries, massive lower gastro-intestinal hemorrhage in India affects younger patients, has different causes and carries a lower mortality. Colonoscopy is useful in making diagnosis during active lower intestinal bleeding in about one-third cases. Exploratory laparotomy and Intra-operative endoscopy are complimentary to above examination and can make the diagnosis in most of the remaining cases.

Massive lower gastrointestinal bleeding as a presenting feature of Behcet's disease.

This reports a 27 yr old female Patient with seronegative polyarthritis who presented with lower GI bleeding and subsequently developed evidence of cutaneous vasculitis (palpable purpura) and orogenital ulcers. The cause of the GI bleeding was multiple ulcerations in the terminal ileum, cecum ascending colon and transverse colon. Continued and massive bleeding necessitated surgical resection of the involved segment of gut which on histopathological examination confirmed the presence of vasculities. This patient was thus diagnosed as having Behcet's disease. Although major GI bleeding is a rare manifestation of Behcet's disease with vasculitis of the gut, one must consider this possibility if the patient has multi-system involvement with evidence of vasculitis involving the skin in the form of palpable purpura.