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CC BY 4.0 · Journal of Digestive Endoscopy
DOI: 10.1055/s-0045-1810429
Original Article

Etiological Spectrum and Clinical Profile of Lower Gastrointestinal Bleed in a Tertiary Care Center: A Retrospective Analysis

Mukesh K. Jain
1   Department of Gastroenterology, SMS Hospital, Jaipur, Rajasthan, India
,
Vivek Pandey 
1   Department of Gastroenterology, SMS Hospital, Jaipur, Rajasthan, India
,
Shashank Singh 
1   Department of Gastroenterology, SMS Hospital, Jaipur, Rajasthan, India
,
Gaurav Gupta
1   Department of Gastroenterology, SMS Hospital, Jaipur, Rajasthan, India
,
Rupesh K. Pokharna
1   Department of Gastroenterology, SMS Hospital, Jaipur, Rajasthan, India
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Abstract

Background

Gastrointestinal (GI) bleeding is one of the most frequently encountered medical and surgical emergencies in gastroenterology practice. The etiology and epidemiology of lower gastrointestinal bleeding (LGIB) vary with age and are influenced by factors such as lifestyle, smoking habits, medication history, and the aging population. The underlying causes of LGIB differ across age groups, with distinct patterns observed in pediatric, adult, and elderly populations. This study aimed to evaluate the etiological and clinical spectrum of LGIB in a tertiary referral center.

Materials and Methods

This was a single-center, cross-sectional retrospective study conducted in the Department of Gastroenterology at a leading tertiary referral center in northwest India. A total of 1,000 patients who presented with LGIB and underwent colonoscopic evaluation were included in the study.

Results

Of the 1,000 patients included in the study, 702 (70.2%) were male and 298 (29.8%) were female, with a male-to-female ratio of 2.35:1. A total of 678 (67.8%) patients were below 60 years of age, whereas 322 (32.2%) were aged 60 years and above. The most common presenting symptom was hematochezia, observed in 658 (65.8%) patients. Stool occult blood was positive in 26 (2.6%) cases.

The most frequent colonoscopic finding was colitis—characterized by loss of vascular pattern, erosions, and ulcerations—seen in 287 (28.7%) patients. This was followed by hemorrhoids in 259 (25.9%), ulceroproliferative growths in 217 (21.7%), and isolated ulcers in 71 (7.1%).

The leading etiology of LGIB was hemorrhoidal bleeding, accounting for 259 (25.9%) patients, followed by colorectal carcinoma (CRC) in 185 (18.5%), inflammatory bowel disease in 139 (13.9%), solitary rectal ulcer syndrome (SRUS) in 65 (6.5%), radiation proctitis in 49 (4.9%), infectious colitis in 41 (4.1%), and GI tuberculosis in 29 (2.9%). The overall diagnostic yield of colonoscopy in this study was 86.7%.

Conclusion

LGIB is a common clinical presentation and a frequent cause of hospital visits. It may present overtly with hematochezia or manifest as occult bleeding, often resulting in anemia. The clinical presentation and underlying etiology vary based on age, sex, geographic location, and comorbid conditions. In India, anorectal causes such as hemorrhoids and SRUS are the most common etiologies of LGIB, followed by CRC. Colonoscopy remains the primary and most valuable diagnostic tool for evaluating patients with LGIB.


 

Keywords

angioectasia - lower gastrointestinal bleeding - colitis - colorectal carcinoma - inflammatory bowel disease - solitary rectal ulcer syndrome - ulcerative colitis - upper gastrointestinal bleeding - colonoscopy

Introduction

Gastrointestinal (GI) bleeding is one of the most frequently encountered medical and surgical emergencies in gastroenterology practice. GI bleeding can originate from the esophagus, stomach, or duodenum up to the ligament of Treitz and is traditionally referred to as upper gastrointestinal bleeding (UGIB). In contrast, lower gastrointestinal bleeding (LGIB) is defined as blood loss from the GI tract distal to the ligament of Treitz.[1] It commonly presents as hematochezia—the passage of maroon or bright red blood or clots per rectum. LGIB accounts for nearly 20% of all cases of acute GI bleeding.[2] Acute LGIB is arbitrarily defined as bleeding lasting less than 3 days, leading to hemodynamic instability, anemia, and/or the need for blood transfusion. Chronic LGIB refers to a slow blood loss occurring over several days. In Western countries, the incidence of LGIB ranges from 20.5 to 27 cases per 100,000 adults annually.[3] Compared with UGIB, patients with LGIB typically present with higher hemoglobin levels, require fewer blood transfusions, and are less likely to develop hypovolemic shock.[4]

The severity of LGIB varies significantly—from mild, intermittent bleeding that often resolves spontaneously to life-threatening massive hemorrhage necessitating urgent interventions. The causes and epidemiology of LGIB differ by age, lifestyle factors, dietary habits, smoking, drug intake, and the general aging of the population. Notably, the incidence and risk of LGIB increase significantly with age, showing a 200-fold rise from the third to the ninth decade of life.[3]

Etiologically, LGIB differs across age groups. In the pediatric population, the common causes are distinct from those seen in adults and the elderly.[5] In Western populations, diverticulosis accounts for the majority (60%) of LGIB cases, followed by inflammatory bowel disease (IBD), ischemic colitis, anorectal disorders (11%), neoplasms (9%), and angiodysplasia (3%).[6] Conversely, in the Indian population, the etiological spectrum is markedly different. Hemorrhoids and IBD are more prevalent than diverticular bleeding. A major Indian study identified hemorrhoids (19.5%), IBD (19.5%), colorectal carcinoma (CRC, 17.4%), infective causes (11.6%), and radiation proctitis (9.4%) as the most common etiologies.[7] Among patients under 60 years of age, IBD is the most common cause, whereas CRC predominates in those over 60.[8]

Colonoscopy remains the primary diagnostic modality for identifying the source of LGIB, as subsequent management depends heavily on the location and nature of the lesion. Multiple studies have confirmed that early colonoscopy (within 24 hours) is both safe and effective, with a diagnostic yield ranging from 45 to 95%.[9]

Despite the burden of LGIB in India, especially in its northern regions, there is limited literature addressing its etiological spectrum. Existing studies are restricted by small sample sizes and regional heterogeneity. This study, conducted at a high-volume tertiary care center in northwest India, aims to fill this gap by providing robust data on the causes of LGIB and highlighting emerging trends. It also evaluates the diagnostic effectiveness of colonoscopy in the evaluation of LGIB.


 

Materials and Methods

It was a single-center, cross-sectional, retrospective study performed in a high-volume tertiary referral center in northwest India. Approval was obtained from the Institutional Ethics Committee. The study included all patients presenting with LGIB to both the outpatient and inpatient departments of the Department of Gastroenterology, SMS Hospital, over a 1-year period—from August 1, 2023 to July 31, 2024. Only those patients who had undergone both upper gastrointestinal endoscopy and colonoscopy were included.

Data were retrieved from patient case sheets and departmental case registers. Patients were included, if they presented with clinical features of lower GI bleeding, such as hematochezia, melena, or stool positive for occult blood, and subsequently underwent colonoscopy. Demographic details and colonoscopic findings were documented from the available records.

Patients were excluded, if they had inadequate bowel preparation or if colonoscopy was incomplete.

The primary objective of the study was to evaluate the etiological spectrum and the clinical and demographic profile of patients presenting with lower GI bleeding. The secondary objectives were to determine the relative frequency of different etiologies and to assess the diagnostic yield of colonoscopy in cases of LGIB.


 

Statistical Analysis

Continuous variables were expressed as mean ± standard deviation, whereas categorical variables were represented as frequencies and percentages. To enhance clarity and interpretation, data were compiled in tabular form and supplemented with pictorial representations, including pie charts where appropriate.


 

Results

A total of 1,000 patients presenting with LGIB were included in the study. Among them, 702 (70.2%) were male and 298 (29.8%) were female, yielding a male-to-female ratio of 2.35:1. A total of 678 patients (67.8%) were aged below 60 years, whereas 322 patients (32.2%) were aged 60 years or older.

The most common clinical presentation was hematochezia, observed in 658 patients (65.8%), followed by occult blood positivity in stool in 26 patients (2.6%). Comorbidities were present in 261 patients (26.1%). A history of nonsteroidal anti-inflammatory drug use was reported in 21 patients (2.1%), whereas prior radiotherapy was documented in 67 patients (6.7%). The demographic and clinical characteristics of the study population are summarized in [Table 1].

Table 1

Demographic and clinical characteristics of the patients

N = 1,000

Percentage

Age (y)

Mean 48.27 ± 17.46

< 60

>60

678

322

67.8

32.2

Sex

Male

702

70.2

Female

298

29.8

Clinical presentation

Hematochezia

Bleeding P/R

Melena

Stool for occult blood +

658

257

59

26

65.8

25.7

5.9

2.6

Comorbidity

Hypertension

Diabetes

CKD

CLD

No Comorbidity

54

37

17

153

739

5.4

3.7

1.7

15.3

73.9

H/O NSAIDs use

21

2.1

Anemia

82

8.2

Coagulopathy

132

13.2

H/O radiotherapy

67

6.7

Abbreviations: CKD, chronic kidney disease; CLD, chronic liver disease; NSAIDs, nonsteroidal anti-inflammatory drugs; P/R, per rectal.


Colonoscopic Findings

The most frequent colonoscopic abnormality was colitis—characterized by loss of vascular pattern, erosions, hemorrhage, and ulcerations—seen in 287 patients (28.7%) ([Fig. 1A]). This was followed by:

Zoom
Fig. 1 Colonoscopic images showing (A) colitis, (B) ulceroproliferative growth, (C) rectal ulcer, and (D) angioectasia.

  • Hemorrhoids in 259 patients (25.9%).

  • Ulceroproliferative growths in 217 patients (21.7%) ([Fig. 1B]).

  • Isolated ulcers in 71 patients (7.1%) ([Fig. 1C]).

  • Polyps/polypoidal growths in 41 patients (4.1%).

  • Nodularity in 33 patients (3.3%).

  • Angioectasia in 19 patients (1.9%) ([Fig. 1D]).

In 133 patients (13.3%), colonoscopy did not reveal any abnormal findings. The distribution of colonoscopic findings is detailed in [Table 2].

Table 2

Colonoscopic findings in patients with lower gastrointestinal bleeding

Number of patients

Percentage[a]

Hemorrhoids

259

25.9

Colitis (loss of vascular pattern, erosions, and ulceration)

287

28.7

Ulceroproliferative growth

217

21.7

Ulcers

71

7.1

Polyp/polypoidal growth

41

4.1

Nodularity

33

3.3

Angioectasia

19

1.9

Normal findings

133

13.3

a  > 100 as more than one finding was present in some patients.



 

Etiological Spectrum of Lower Gastrointestinal Bleeding

The leading cause of lower GI bleeding was hemorrhoidal bleeding, identified in 259 patients (25.9%), followed by CRC, diagnosed in 185 patients (18.5%), predominantly among patients aged over 60. Other notable etiologies included:

  • IBD in 139 patients (13.9%), of which:

    • ○ Ulcerative colitis (UC): 131 patients (13.1%).

    • ○ Crohn's disease: 8 patients (0.8%).

  • Solitary rectal ulcer syndrome (SRUS): 65 patients (6.5%).

  • Radiation proctitis: 49 patients (4.9%).

  • Infectious colitis: 41 patients (4.1%).

  • Tubercular colitis: 29 patients (2.9%).

  • Ischemic colitis: 25 patients (2.5%).

  • Unknown etiology: 27 patients (2.7%).

The detailed breakdown of etiological diagnoses and infectious causes of colitis is provided in [Figs. 2] and [3], respectively.

Zoom
Fig. 2 Pie diagram depicting etiological distribution in patients with lower gastrointestinal bleeding.
Zoom
Fig. 3 Pie diagram depicting the etiological spectrum of infectious colitis.

 

 

Discussion

LGIB may present as overt bleeding, such as hematochezia or melena, or remain occult. The age of presentation varies significantly, and LGIB is known to be associated with considerable morbidity and, at times, mortality.[10] The clinical spectrum ranges from mild self-limiting bleeding to life-threatening hemorrhage necessitating hospitalization, endoscopic intervention, or even surgery.[11] Notably, Indian patients often present at a younger age compared with Western populations.[12]

In our study, the mean age of presentation was 48.27 ± 17.46 years, with a male predominance (male-to-female ratio of 2.35:1). This observation is consistent with findings by Hajare and Kantamaneni, who reported a mean age of 43.82 ± 17.96 years,[10] and Lakhanpal et al, where the majority of patients were between 40 and 59 years (mean age: 49.5 years; M:F ratio: 1.19:1).[7] Similarly, Mehrotra et al also reported a higher proportion of male patients (69.8%).[13] The younger age at diagnosis in our cohort may be attributed to increasing public awareness and improvements in health care access and diagnostic modalities.

Hemorrhoids (25.9%) were the most frequent cause of LGIB in our cohort, followed by CRC (18.5%), IBD (13.9%), SRUS (6.5%), infectious colitis (4.1%), and tuberculosis (2.9%). These findings align with previous studies: Goenka et al identified UC (19.3%), acute colitis (12%), radiation proctitis (9%), SRUS (7.8%), and tuberculosis (4.2%) as leading causes.[8] Lakhanpal et al also reported anorectal causes and IBD (each 19.56%) and CRC (17.39%) as common etiologies.[7] Soni et al observed UC (40%) and hemorrhoids (30.83%) as the predominant causes of rectal bleeding.[14]

Our study's findings mirror earlier research, particularly after excluding anorectal causes. CRC and UC emerged as the most prevalent etiologies of LGIB. The relatively high proportion of CRC in our population may reflect changes in dietary habits, lifestyle factors, and increased access to cancer screening programs. Global epidemiological studies have indicated a rising trend in CRC incidence over the past two decades.[15] This trend reinforces the importance of performing full-length colonoscopy, rather than limited sigmoidoscopy, in patients with LGIB to avoid missing proximal colonic lesions.

Radiation proctitis was diagnosed in 4.9% of our patients, and 6.7% had a history of prior pelvic radiotherapy, likely due to our institute's status as a tertiary referral center managing a high burden of pelvic malignancies. Anemia was present in 8.2% of patients, while fecal occult blood test (FOBT) was positive in 2.6%, indicating a noteworthy proportion of occult presentations. This emphasizes the need for colonoscopic evaluation in patients with unexplained anemia or positive FOBT results.

Ischemic colitis, found in 2.5% of cases, is more common in the elderly and in those with cardiovascular risk factors like hypertension and diabetes. Infections and tuberculosis continue to be relevant causes of LGIB in developing countries such as India. Colonoscopic biopsy remains the gold standard for diagnosing infectious colitis and differentiating it from IBD, which is essential due to differing treatment pathways.

Despite advanced age and comorbidities, most patients with LGIB had favorable outcomes. Compared with upper GI bleeding (UGIB), LGIB typically carries a lower mortality risk and requires fewer interventions. In our study, only 33 patients (3.3%) required hospitalization, and mortality was observed in 9 patients (0.9%).

This study, conducted at a tertiary care center, provides valuable insights based on a large sample of patients with LGIB, aiding future clinical decision-making. Its major strength lies in the large sample size and comprehensive colonoscopic and etiological profiling. However, notable limitations include the exclusion of enteroscopy and capsule endoscopy data for patients with normal colonoscopy results. Moreover, since the study predominantly included adults over 18 years of age, the findings may not be generalizable to the pediatric population.


 

Conclusion

LGIB is a significant clinical presentation and a common reason for hospital visits, although its incidence remains lower than that of UGIB. The presentation of LGIB varies widely—from overt bleeding to occult blood loss manifesting as iron deficiency anemia—and is influenced by factors such as age, sex, geographical location, and the presence of comorbidities. In India, anorectal disorders such as hemorrhoids and SRUS, followed by CRC and UC, constitute the most common causes of LGIB, differing notably from patterns seen in Western countries. Colonoscopy continues to be the cornerstone in the evaluation of LGIB, enabling both diagnostic accuracy and therapeutic interventions.


 

 

Conflict of Interest

None declared.


Address for correspondence

Vivek Pandey, MBBS, MD, DM
Room No F-7, Resident Doctor Hostel, SMS Medical College and Hospital, Jaipur 302004, Rajasthan
India   

Publikationsverlauf

Artikel online veröffentlicht:
04. August 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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Zoom
Fig. 1 Colonoscopic images showing (A) colitis, (B) ulceroproliferative growth, (C) rectal ulcer, and (D) angioectasia.
Zoom
Fig. 2 Pie diagram depicting etiological distribution in patients with lower gastrointestinal bleeding.
Zoom
Fig. 3 Pie diagram depicting the etiological spectrum of infectious colitis.