Acute major lower gi hemorrhage in inflammatory bowel disease

Background: Acute major lower GI hemorrhage is an uncommon, though potentially serious, manifestation of inflammatory bowel disease (IBD). Our aim was to characterize all patients with IBD requiring intervention by the GI Bleeding Team. Methods: From 1988 to 1996, 983 patients with acute lower GI bleeding were seen, of which 22 (2.2%) were due to IBD. Major bleeding was defined as blood per rectum with hemodynamic instability (hypotension or orthostatic change in vital signs) and/or a drop in hemoglobin concentration of at least 2 gm/dL. Results: 19 patients had Crohn's disease (CD) and 3 had ulcerative colitis (UC). There were 16 men and 6 women with a mean age of 46 years (range, 12-88). In five (23%), the bleed led to the diagnosis of IBD. In the remaining 17, the median duration of disease was 7 years (1 mo-36 yr). In 18 (82%), the site of bleeding was identified endoscopically. Colonoscopy was non-diagnostic in 4 cases due to excessive bleeding (2), a colonic stricture (1), or ileal angulation (1), and all four required surgery. For CD, the site of bleeding was jejunoileal in 1, ileal in 5, ileocolonic in 6, and colonic in 7. The UC patients all had pancolitis. Median blood transfusion requirement was 6 units of RBC's (range 0-37). Initial treatment was with corticosteroids in 16, surgery in 5, and 5-ASA in 1. Only one patient (with CD) had an identifiable focal bleeding site, and this was successfully treated endoscopically (epinephrine injection with bicap coagulation). Of the 16 patients treated with steroids, 4 required surgery within 1-4 days for bleeding. There were four recurrent major hemorrhages (3 CD, 1 UC) during the initial hospitalization (IH) and one of these led to urgent surgery. Median follow-up was seven months (range 0-84), during which one patient with CD had a third major hemorrhage 6 years following the index bleed, and died of complications of blood loss. There were no other bleeding-related deaths during the IH or follow-up. Conclusions: 1. IBD was an uncommon cause of major GI bleeding. 2. Most cases were due to CD without a predilection for site of involvement. 3. The presence of an endoscopically treatable lesion was uncommon. 4. Surgery was often required (41%) during the IH. 5. Recurrent major hemorrhage was uncommon, occurring most often during the IH.