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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Lower gastrointestinal bleeding, commonly abbreviated LGIB, refers to any form of bleeding in the lower gastrointestinal tract.

Causes

Diagnosis

The following suggest an LGIB:

The following may suggest an LGIB:

Related Chapter

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood in stools
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fever
 
 
 
 
 
 
Rectal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
H/O of constipation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
H/O of constipation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weightloss
 
 
 
 
 
Diverticulosis
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamic status
 
 
 
 
 
 
Diverticulitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
 
Unstable
 
 
 
 
 
 
 
 
Polyps
 
 
 
 
 
Colon cancer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight Loss
 
 
 
 
 
 
Anal fissure
External Hemmrhoids
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rectal cancer
Colon cancer
 
 
 
 
 
 
 
Angiodysplasia
Polyps

Management

Hepatic adenoma

Management of hepatic adenoma depends upon:

  • Symptoms
  • Size
  • Number
  • Location
  • Certainty of the diagnosis

Asymptomatic woman on OCPs with a small adenoma

The European Association for Study of the Liver recommends

  • Discontinuation of contraceptive medication
  • Close observation of the lesion with repeated imaging and alpha fetoprotein.
    • Contrast-enhanced magnetic resonance imaging at a six month interval to determine if there is regression of a large adenoma to less than 5 cm.
  • Patients with hepatic adenomas that do not resolve or that enlarge after six months of observation should undergo treatment.

Symptomatic patients and those with large adenomas

  • Surgical resection is recommended for all symptomatic patients with hepatic adenoma and those with large lesions (>5 cm).
  • Surgical options include :
    • Enucleation
    • Resection
    • Liver transplantation
  • Nonsurgical interventions include
    • Transarterial embolization
    • Radiofrequency ablation

Hepatic Hemangioma

  • Asymptomatic patients
    • Patients with lesions <1.5 cm, are reassured and observed.
    • Follow-up imaging in patients with hemangiomas ≤5 cm in size is usually not recommended.
    • Patients with rapid growth of a hemangioma or with lesions >5 cm it is recommended to repeat imaging in 6 to 12 months.
    • It is recommended not perform additional imaging if there is no change in the size of the lesion.  
  • Symptomatic patients
    • Patients who have pain or symptoms suggestive of extrinsic compression of adjacent structures should be considered for surgical options.
    • Surgical options include 
      • Liver resection
      • Enucleation
      • Hepatic artery ligation
      • Liver transplantation
    • Non-surgical techniques include
      • Hepatic artery embolization
      • Radiotherapy
      • Interferon alfa-2a 

Focal nodular hyperplasia

  • Due to their benign nature of focal nodular hyperplasia, there is
  • Follow-up studies at three and six months will often be sufficient to confirm the stability of the lesion and its benign nature, after which no long-term follow-up is required routinely.
  • Surgery should be reserved for symptomatic FNH lesion.
Parasitic Infection Mode of infection Epidemiology Clinical manifestations  Diagnosis Treatment
Disease Parasite Incidence Geographic distrubution
Ascariasis Ascaris lumbricoides
  • Ingestion of Ascaris eggs secreted in the feces of humans or pigs.[1]
  • Ingesting uncooked pig or chicken liver with the larvae.
  • Ascariasis affects at least 1 billion people worldwide and about 4 million people in the United States.[2]
  • Asia
  • Africa
  • South America
Necatoriasis  Necator americanus 
  • Skin contact
  • Approximately 800 million people are infected with hookworms worldwide.[3]
  • Brazil
  • Texas
  • Africa
  • China
  • Southwest Pacific islands
  • India
  • Southeast Asia
Giardiasis Giardia lamblia
  • Ingestion of raw or undercooked food contaminated with cysts.[9]
  • Approximately, 15,223 cases were reported in the United States in 2012.[10]
 Fasciolosis 
Schistosomiasis
Strongyloidiasis
Amoebiais
Taeniasis
Trichuriasis Trichuris trichiura
  • Ingestion of embryonatedeggs from contaminated drinking water and food.
  • Endemic in tropical and subtropical countries.
  •  Southern United States
  • Incidence and prevalence rates are highest in children living in
    • Sub-Saharan Africa
    • Asia
    • Latin America
    • Caribbean
  • Stool microscopy
  • Proctoscopy
    • Demonstrates adult worms protruding from the bowel mucosa.
Hymenolepiasis Hymenolepis nana
  • Ingestion of infected eggs
Most common in temperate zones[15]
  • South Europe
  • Russia
  • India
  • US
  • Latin America.
  • Asymptomatic[16]
  • Heavy infections with >1000 worms can occur
  • Stool microscopy
  1. Permin A, Henningsen E, Murrell KD, Roepstorff A, Nansen P (2000). "Pigs become infected after ingestion of livers and lungs from chickens infected with Ascaris of pig origin". Int J Parasitol. 30 (7): 867–8. PMID 10899534.
  2. Betson M, Nejsum P, Bendall RP, Deb RM, Stothard JR (2014). "Molecular epidemiology of ascariasis: a global perspective on the transmission dynamics of Ascaris in people and pigs". J Infect Dis. 210 (6): 932–41. doi:10.1093/infdis/jiu193. PMC 4136802. PMID 24688073.
  3. Bradbury RS, Hii SF, Harrington H, Speare R, Traub R (2017). "Ancylostoma ceylanicum Hookworm in the Solomon Islands". Emerg Infect Dis. 23 (2): 252–257. doi:10.3201/eid2302.160822. PMC 5324822. PMID 28098526.
  4. Nawalinski TA, Schad GA (1974). "Arrested development in Ancylostoma duodenale: course of a self-induced infection in man". Am J Trop Med Hyg. 23 (5): 895–8. PMID 4451228.
  5. Chhabra P, Bhasin DK (2017). "Hookworm-Induced Obscure Overt Gastrointestinal Bleeding". Clin Gastroenterol Hepatol. 15 (11): e161–e162. doi:10.1016/j.cgh.2017.02.034. PMID 28300694.
  6. McKenna ML, McAtee S, Bryan PE, Jeun R, Ward T, Kraus J; et al. (2017). "Human Intestinal Parasite Burden and Poor Sanitation in Rural Alabama". Am J Trop Med Hyg. 97 (5): 1623–1628. doi:10.4269/ajtmh.17-0396. PMID 29016326.
  7. Genta RM, Woods KL (1991). "Endoscopic diagnosis of hookworm infection". Gastrointest Endosc. 37 (4): 476–8. PMID 1916173.
  8. Serre-Delcor N, Treviño B, Monge B, Salvador F, Torrus D, Gutiérrez-Gutiérrez B; et al. (2017). "Eosinophilia prevalence and related factors in travel and immigrants of the network +REDIVI". Enferm Infecc Microbiol Clin. 35 (10): 617–623. doi:10.1016/j.eimc.2016.02.024. PMID 27032297.
  9. Quick R, Paugh K, Addiss D, Kobayashi J, Baron R (1992). "Restaurant-associated outbreak of giardiasis". J Infect Dis. 166 (3): 673–6. PMID 1500757.
  10. Muhsen K, Levine MM (2012). "A systematic review and meta-analysis of the association between Giardia lamblia and endemic pediatric diarrhea in developing countries". Clin Infect Dis. 55 Suppl 4: S271–93. doi:10.1093/cid/cis762. PMC 3502312. PMID 23169940.
  11. Pickering LK, Woodward WE, DuPont HL, Sullivan P (1984). "Occurrence of Giardia lamblia in children in day care centers". J Pediatr. 104 (4): 522–6. PMID 6707812.
  12. Forrester JE, Bailar JC, Esrey SA, José MV, Castillejos BT, Ocampo G (1998). "Randomised trial of albendazole and pyrantel in symptomless trichuriasis in children". Lancet. 352 (9134): 1103–8. PMID 9798586.
  13. Rossignol JF, Maisonneuve H (1984). "Benzimidazoles in the treatment of trichuriasis: a review". Ann Trop Med Parasitol. 78 (2): 135–44. PMID 6378109.
  14. Steinmann P, Utzinger J, Du ZW, Jiang JY, Chen JX, Hattendorf J; et al. (2011). "Efficacy of single-dose and triple-dose albendazole and mebendazole against soil-transmitted helminths and Taenia spp.: a randomized controlled trial". PLoS One. 6 (9): e25003. doi:10.1371/journal.pone.0025003. PMC 3181256. PMID 21980373.
  15. Utzinger J, Botero-Kleiven S, Castelli F, Chiodini PL, Edwards H, Köhler N; et al. (2010). "Microscopic diagnosis of sodium acetate-acetic acid-formalin-fixed stool samples for helminths and intestinal protozoa: a comparison among European reference laboratories". Clin Microbiol Infect. 16 (3): 267–73. doi:10.1111/j.1469-0691.2009.02782.x. PMID 19456836.
  16. Muehlenbachs A, Bhatnagar J, Agudelo CA, Hidron A, Eberhard ML, Mathison BA; et al. (2015). "Malignant Transformation of Hymenolepis nana in a Human Host". N Engl J Med. 373 (19): 1845–52. doi:10.1056/NEJMoa1505892. PMID 26535513.
  17. Steinmann P, Cringoli G, Bruschi F, Matthys B, Lohourignon LK, Castagna B; et al. (2012). "FLOTAC for the diagnosis of Hymenolepis spp. infection: proof-of-concept and comparing diagnostic accuracy with other methods". Parasitol Res. 111 (2): 749–54. doi:10.1007/s00436-012-2895-9. PMID 22461006.
  18. Ohnishi K, Sakamoto N, Kobayashi K, Iwabuchi S, Nakamura-Uchiyama F (2013). "Therapeutic effect of praziquantel against Taeniasis asiatica". Int J Infect Dis. 17 (8): e656–7. doi:10.1016/j.ijid.2013.02.028. PMID 23618773.
  19. Pawłowski ZS (1990). "Efficacy of low doses of praziquantel in taeniasis". Acta Trop. 48 (2): 83–8. PMID 1980572.