- Anorectal conditions account for about 8% in series of patients presenting with hematochezia. It is axiomatic that finding one of these obvious lesions does not preclude the presence of a coexisting, more proximal & more serious lesion.
- Diverticulosis is the most common lower GI cause of hematochezia in adults & is progressively more likely with age. Although melena may occasionally occur it is not characteristic, nor is occult bleeding.
- Neoplasia: Benign & malignant colon polyps as well as sessile & "apple-core" malignancies are increasingly prevalent in elderly patients but also occur as early as the 3rd or 4th decade in genetically predisposed patients. Although they are usually discovered by screening colonoscopy or present with mild intermittent or occult bleeding, they occasionally present with gross hemorrhage.
- Angiodysplasia is probably the next most frequently seen lower GI cause of hematochezia. Two thirds of these patients are over 70 years of age, are more male than female & associated with the presence of aortic valvular stenosis (AVS).
- Inflammatory Bowel Disease (IBD): The peak incidence of IBD is bimodal, the 1st peak occurring in the early 20's & the 2nd around age 70. Ulcerative colitis (UC) is much more likely to present with hematochezia than is Crohn's disease (CD). Fifteen percent present with UC catastrophic onset; 1% with massive hematochezia.
- Ischemic colitis is a very common cause of hematochezia in the elderly. It is not caused by large artery occlusion but by impaired mucosal perfusion in "watershed areas" between the distributions of major vascular territories. Hence, the most frequent bleeding sites are the splenic flexure, the descending or sigmoid colon. Presentation is usually with cramping left-sided abdominal pain followed within 24 hours by hematochezia. Flat plate of the abdomen may show a classical "thumbprints" in the image of the colonic mucosa at the site of the involved segment.
- Infectious colitis caused by Campylobacter jejuni, Shigella or Salmonella species, pathogenic E. coli, Clostridium difficile or E. coli 0157:H7 may cause bloody diarrhea. Blood loss is rarely significant.
- Fecal Impaction has been reported as a cause of clinically significant hematochezia, usually occurring as a result of manual disimpaction.
- Rectal or colonic varices, usually caused by portal hypertension (termed "portal colonopathy") may occasionally cause recurrent hematochezia.
- Intussusception of the small bowel or colon is an infrequent cause of hematochezia. Aortoenteric fistula has been described as a cause of hematochezia in adults.
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