How did the pathogenesis, diagnosis, and treatment of lower GI bleeding (LGIB) evolve over the 20th century?

Updated: Jul 26, 2019
  • Author: Burt Cagir, MD, FACS; Chief Editor: BS Anand, MD  more...
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Answer

Understanding of the pathogenesis, diagnosis, and treatment of LGIB has drastically changed during the last 50 years. In the first half of the 20th century, large intestinal neoplasms were believed to be the most common cause of LGIB. In the 1950s, this condition was commonly attributed to diverticulosis; surgical treatment consisted of blind segmental bowel resections, with disappointing results. Patients who underwent these procedures suffered from a prohibitively high rebleeding rate (up to 75%), morbidity (up to 83%), and mortality (up to 60%).

Over several decades, diagnostic methods for locating the precise bleeding point greatly improved. The flexible endoscope was developed in 1954. The full-length colonoscope was developed in 1965 in Japan. Also in 1965, Baum et al described selective mesenteric angiography, which permitted the identification of vascular abnormalities and the precise bleeding point. [7] The first anal colonoscopy was performed in 1969.

Experience with mesenteric angiography in the late 1960s and 1970s suggested that angiodysplasias and diverticulosis were the most common reasons for LGIB. Since its discovery, mesenteric angiography remains the criterion standard in precise localization of the bleeding site.

Rosch et al described superselective visceral arteriography for infusion of vasoconstrictors in 1971 and superselective embolization of the mesenteric vessels as an alternative technique to treat massive LGIB in 1972. [8, 9] The most feared complication of embolization of the mesenteric vessels is ischemic colitis, which has limited its use in GI bleeding.

The initial experience with vasopressin infusion was reported in 1973-1974. Vasopressin causes vasoconstriction and arrests the bleeding in 36%-100% of patients. The recurrence rate following completion of vasopressin infusion can be as high as 71%; therefore, vasopressin is used to temporize the acute event and to stabilize patients before surgery.

Endoscopic control of bleeding with thermal modalities or sclerosing agents has been in use since the 1980s. One of the advantages of upper (or lower) endoscopic evaluation is that it provides a means to administer therapy in patients with GI bleeding. Nuclear scintigraphy has been used since the early 1980s as a very sensitive diagnostic tool to evaluate bleeding from the GI tract; this modality can detect hemorrhage at rates as low as 0.1 mL/min.


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