Lower Gastrointestinal Bleeding: Uncovering Geographic Variations in Cause and Care

Lower gastrointestinal bleeding (LGIB) remains a significant clinical challenge worldwide. While diagnostic and therapeutic advancements have improved patient outcomes, the etiological spectrum varies widely across regions. These differences stem from dietary habits, health care access, socioeconomic factors, and disease prevalence.

LGIB, defined as bleeding distal to the ligament of Treitz, ranges from minor self-limiting episodes to severe hemorrhages. In Western countries, it predominantly affects older adults due to diverticulosis, angiodysplasia, ischemic colitis, and malignancies. Diverticular disease alone accounts for 30 to 50% of cases in the elderly.[1] The availability of colonoscopy, single- and double-balloon enteroscopy, capsule endoscopy, CT (computed tomography) angiography/enterography, magnetic resonance (MR) enterography, and interventional radiology (IR) has improved diagnostic and therapeutic outcomes in these settings.

In contrast to the West, LGIB in India often results from hemorrhoids, inflammatory bowel disease (IBD), colorectal cancer, polyps, angiodysplasia, and infective colitis.[2] [3] Infective causes, including amebiasis and tuberculosis, remain significant due to challenges in sanitation and public health. A traditional high-fiber diet prevalent in India lowers the incidence of diverticulosis, which remains a leading cause in the West. The current study by Mathew et al published in the current issue of Journal of Digestive Endoscopy highlights the clinical characteristics, diagnostic evaluation, therapeutic interventions, and outcomes of patients with LGIB at a tertiary care center in South India.[4]

Indian LGIB patients are generally younger (30–50 years) and predominantly male.[2] [3] In the current study, the mean age is 50 years, with a male predominance of 72%. Conversely, Western cohorts are older (60–70 years) and have more comorbidities (e.g., hypertension, coronary artery disease, anticoagulant use). Hematochezia is the most common presenting symptom in both populations, although massive bleeding and hemodynamic instability are more frequent in older Western patients with vascular lesions.

Colonoscopy remains the cornerstone of LGIB diagnosis globally,[5] with Indian tertiary centers achieving diagnostic yields of 60 to 87.5%.[2] [3] The current study has a diagnostic yield of 61%. When initial colonoscopy is inconclusive, Western centers employ CT angiography and IR embolization extensively, while such modalities are less frequently used in India, possibly due to resource limitations. I always wonder whether we are evaluating small bowel source of bleeding in all cases where a colonoscopy being negative. A major limitation in evaluating small bowel sources of LGIB is the nonavailability of enteroscopy and capsule endoscopy at most centers. These modalities offer greater sensitivity than conventional CT or MR enterography, potentially explaining the high proportion of patients in whom the bleeding source remains unidentified (3–30%). In the current study, the source of bleeding remained unidentified in 14% of patients, even after the use of capsule endoscopy. However, advancement in the technology including artificial intelligence and machine learning can further increase the diagnostic yield.Conservative management is a primary strategy in line with this study across both Western and Indian patient groups. Nevertheless, therapeutic strategies share common elements like endoscopic interventions (polypectomy, coagulation), medical treatment for IBD and infections, and surgery, mainly for cancerous conditions.

Western series report LGIB mortality rates of 2 to 4%, primarily driven by age, comorbidities, and in-hospital bleeds.[6] Rebleeding is common with diverticular disease, with recurrence rates up to 10%.[7] Indian data on mortality and recurrence are limited but suggest lower fatality rates due to the younger patient population and lower prevalence of diverticular disease. In the present study, the mortality rate was 5.3% and it was mostly attributed to comorbid conditions rather than uncontrolled bleeding.

Transfusion requirements remain high in severe cases, with 20% of Western patients needing ≥4 units of red blood cells. Indian studies report frequent anemia but lack specific transfusion data. Hospital stays average 4 days in Western cohorts, whereas Indian data are sparse.

Challenges and Regional Realities

India faces unique challenges in LGIB management:

• Resource limitations affect access to advanced diagnostics and interventions.

• Delayed health care–seeking behavior leads to advanced presentations.

• Infective etiologies remain prevalent, necessitating infection control measures.

• Infrastructure constraints impact timely interventions.

With urbanization and changing lifestyles, India may face an increase in diverticulosis and colorectal cancer prevalence. Proactive measures, such as colorectal cancer screening programs and promotion of high-fiber diets, are essential to mitigate this shift.

Conclusion

LGIB reflects the interplay between regional epidemiology and health care systems. While Western countries deal predominantly with diverticular and vascular causes in older patients, Indian cohorts face IBD, infective etiologies, hemorrhoidal bleeding, and younger patient demographics. Both regions use similar diagnostic and therapeutic approaches, but resource availability influences outcomes. Tailoring guidelines to local contexts, backed by indigenous data, is essential for improving LGIB management in India. With targeted interventions, policy support, and health care capacity building, we can improve outcomes and even surpass Western standards.

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• References

• 1 Strate LL, Gralnek IM. ACG clinical guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol 2016; 111 (04) 459-474
• 2 Dar IA, Dar WR, Khan MA. et al. Etiology, clinical presentation, diagnosis and management of lower gastrointestinal bleed in a tertiary care hospital in India: a retrospective study. J Dig Endosc 2015; 6: 101-109
• 3 Lakhanpal V, Sharma R, Bodh V, Thakur S, Sharma N, Sharma B. Clinical spectrum of chronic lower gastrointestinal bleeding at sub-Himalayas: a study at tertiary care hospital of north India. J Dig Endosc 2019; 10 (03) 158-162
• 4 Mathew. et al. Lower gastrointestinal bleeding: etiology and outcomes at a tertiary care centre in South India. Are these different from the West?. J Dig Endosc
• 5 Oakland K, Chadwick G, East JE. et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019; 68 (05) 776-789
• 6 Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol 2010; 105 (12) 2636-2641 , quiz 2642
• 7 Patel SD, Desai R, Patel U. et al. Thirty-day readmissions after upper and lower gastrointestinal hemorrhage: a national perspective in the United States. J Clin Gastroenterol 2019; 53 (08) 582-590

Publikationsverlauf

Artikel online veröffentlicht:
12. Juni 2025