Lower Gastrointestinal Bleeding in the Elderly
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INTRODUCTION
Lower gastrointestinal (GI) bleeding is a significant cause of increased morbidity and mortality in the elderly. The incidence of lower GI bleeding increases with age, with a greater than 200-fold increase from the third to the ninth decade of life. The incidence of lower GI bleeding in the United States ranges from 20.5 to 27 per 100,000 persons per year, and is more common in men than women.1 The increased incidence of lower GI bleeding in the elderly corresponds to the increased incidence of specific GI diseases, the increased incidence of comorbid illnesses, and more polypharmacy. GI illnesses associated with lower GI bleeding that are more common in the elderly include diverticulosis coli, vascular ectasia, ischemic colitis, and colonic neoplasms. Hemorrhage and the presence of serious concurrent illness are the two most important factors in predicting mortality among patients with GI bleeding.2 Comorbid illnesses include atherosclerotic cardiovascular disease, cerebrovascular disease, and malignancy. Anticoagulant and nonsteroidal anti-inflammatory drug (NSAID) use increases the probability of GI bleeding.
PATHOPHYSIOLOGY OF LOWER GI BLEEDING
Lower GI bleeding can be acute bleeding, occult bleeding, or obscure bleeding. Acute lower GI bleeding presents as melena or hematochezia. Occult bleeding is usually detected with stool guaiac testing and is the most common presentation of lower GI bleeding in the elderly, occurring in 10% of the adult population. Remarkably, patients losing 100 mL of blood per day may have grossly normal-appearing stools.3,4 Obscure bleeding is when the source of bleeding is difficult to detect on routine endoscopic and radiologic examinations. The source of bleeding is unidentified in approximately 5% of patients.5
CAUSES OF LOWER GI BLEEDING
There are many causes of lower GI bleeding in the elderly (Table I). The most common causes of lower GI bleeding are diverticular disease and vascular ectasias. Less common causes of lower GI bleeding are inflammatory diseases of the colon due to infectious colitis, ischemic colitis, idiopathic inflammatory bowel disease, post-irradiation colitis, neoplasms, postpolypectomy hemorrhage, and hemorrhoids. There are additional rarer causes that include Dieulafoy’s lesion and colorectal varices.6,7
Diverticulosis Coli
The incidence of diverticulosis coli increases with age from approximately 5% of individuals at age 40 to 65% at age 85.8 Although most patients with diverticulosis are asymptomatic, approximately 3-5% can develop lower GI bleeding, usually in the form of hematochezia.9 Diverticular disease is the most common cause of lower GI bleeding, with an incidence ranging from 15-48% of patients with lower GI bleeding, depending upon the series. Diverticular hemorrhage can be severe, with a significant morbidity rate of 10-20%. Risk factors for hemorrhage include the use of NSAIDs, lack of dietary fiber, constipation, and advancing age.10-12 Bleeding usually ceases spontaneously, with less than 1% of patients requiring greater than 4 units of blood.9 However, bleeding can become more hemodynamically significant in elderly patients with comorbid conditions, such as cerebrovascular disease or atherosclerotic cardiovascular disease, and in those with polypharmacy who may be taking anticoagulants or NSAIDs.
Vascular Ectasia
Vascular Ectasia or angiodysplasia can occur in the colon and small intestine. They occur with much greater frequency in the elderly than telangiectasia, hemangiomas, or congenital arteriovenous malformations. They are degenerative lesions of previously normal blood vessels that may occur anywhere in the colon, but are more common in the cecum and right colon. Small-bowel vascular ectasia are the most common source of obscure GI bleeding, comprising up to 60% of cases.13,14 Bleeding may manifest itself as iron-deficiency anemia and occult blood-positive stools.
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