Enterorrhagia

Specialty: Gastrointestinal.

• Massive lower digestive bleeding
• profuse intestinal bleeding
• stools with abundant dark or bright red blood

Why it occurs

• Colonic diverticulosis with erosion of the subserous arteriole in the diverticular neck (most common cause of painless massive bleeding)
• Angiodysplasias of the right colon or cecum (common degenerative vascular malformations in the elderly)
• Severe inflammatory bowel disease with deep ulceration and bleeding of the colonic mucosa
• Adenocarcinoma of the left colon, cecum or rectum with tumor ulceration and erosion of medium-caliber vessels
• Ulcerated Meckel's diverticulum with the presence of ectopic acid-producing gastric mucosa (common cause in young people).

Initial workup

Cannulation of two large-caliber peripheral venous lines (14G or 16G) and immediate start of resuscitation with crystalloids and typing for transfusion | Rectal examination and nasogastric tube placement (to exclude massive upper gastrointestinal bleeding with accelerated transit) | Emergency colonoscopy after preparation if the patient is hemodynamically stable | CT angiography of the abdomen (capable of detecting active bleeding with flows >0.3-0.5 ml/min) | Selective mesenteric arteriography for therapeutic purposes (embolization) or scintigraphy with erythrocytes labeled with Technetium-99m.

Standard management

• Transfusion of concentrated red blood cells — to maintain hemoglobin targets >7-8 g/dL, or targets >9 g/dL in patients with a history of active ischemic heart disease
• Terlipressin or somatostatin — in continuous intravenous infusion if bleeding is suspected secondary to ectopic varices in advanced portal hypertension
• Tranexamic acid — 1 g slow IV, although with limited evidence of net benefit in pure lower gastrointestinal bleeding and caution due to prothrombotic risk
• Suspension of antiplatelet agents and anticoagulants, with immediate active reversal depending on the drug (vitamin K, concentrated prothrombin complex or idarucizumab/andexanet alfa).