Lower gastrointestinal bleeding refers to blood loss originating from a site distal to the ligament of Treitz. The aetiology varies depending on the age of patients. Excluding benign anorectal pathology in children and young people, Meckel's diverticulum, juvenile polyps and inflammatory bowel disease are the main causes. Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, being present in about 2% of the general population. Most Meckel's diverticulum are asymptomatic and are diagnosed incidentally. The risk of complications is 4-6%, with bleeding as one of them.

Defecatory disorders are very common complications after left hemicolectomy and anterior rectal resection. These disorders seem related primarily to colonic denervation after the resection. To evaluate the real benefits of inferior mesenteric artery (IMA) preservation via laparoscopic left hemicolectomy performed for diverticular disease in terms of reduced colonic denervation and improved postoperative intestinal functions, a randomized, single-blinded (patients) controlled clinical trial was conducted.From January 2004 to January 2010, patients with symptomatic diverticular disease and a surgical indication were enrolled in the study and randomly assigned to two treatment groups. The first group underwent laparoscopic left hemicolectomy, which preserved the IMA by sectioning the sigmoid arteries one by one near the colonic wall, In the second group, the IMA was sectioned immediately below the origin of left colic artery. Defecation disorders were assessed by anorectal manometry and by three questionnaires to evaluate constipation, incontinence, and quality of life 6 months after the intervention.A total of 107 patients were included in the study. The 54 patients with preserved IMA showed a statistically lower incidence of defecation disorders such as fragmented evacuations, alternating bowel function, constipation, and minor incontinence, as well as less lifestyle alteration than the 53 patients with the IMA sectioned just below the left colic artery.This study confirmed that preservation of the IMA should be recommended to reduce the incidence of defecatory disorders after left hemicolectomy for benign disease.

The epidemiology of lower gastrointestinal bleeding (LGIB) in Western populations has been reported; however, there are scant Asian reports. The aim of the present study was to determine the etiology of LGIB in a Chinese population by reporting a retrospective case series and a systematic analysis of Chinese literature.A large colonoscopy database in a tertiary endoscopic center was searched to identify all patients with the indication of LGIB. The data, including patients' sex, age, endoscopic and pathological findings, were collected and analyzed. A comprehensive database search of the Chinese literature was carried out to obtain all relevant studies.In our series, a total of 720 patients with LGIB were included. There were 425 males and 295 females with a median age of 50 years, the most common etiologies of LGIB were inflammatory bowel disease (IBD; 30.2%), polyps (23.4%) and cancer (10.7%). In 30.2% of all the patients, no obvious causes were identified. A systematic analysis of Chinese literature found an additional 160 studies providing relevant data in 53,951 patients. Overall, colorectal cancer (24.4%), colorectal polyps (24.1%), colitis (16.8%), anorectal disease (9.8%) and IBD (9.5%) were the most common etiologies of LGIB. The main etiologies were different between adults, the elderly and children.The study shows colorectal cancer, colorectal polyps, colitis, anorectal disease and IBD were the most common etiologies of LGIB in the Chinese adult and elderly population, whereas colorectal polyps, chronic colitis and intussusception were the main causes of LGIB in Chinese children. Whereas diverticulum, the most common cause of LGIB in Western populations, is uncommon in China.

Blood in faeces or stains of blood on the surface or toilet paper are common problems among all age groups. Too few patients seek medical consultation because of these symptoms. The differential diagnosis is quite large. Most cases are caused by benign anorectal diseases like hemorrhoids. On the other hand neoplasias of the anus and intestine or inflammatory bowel disease are important diagnoses to be considered. We emphasize that every patient should be seen by a doctor and endoscopic investigation should be discussed.

Lower gastrointestinal hemorrhage accounts for approximately 20% of gastrointestinal hemorrhage. The most common causes of lower gastrointestinal hemorrhage in adults are diverticular disease, inflammatory bowel disease, benign anorectal diseases, intestinal neoplasias, coagulopathies and arterio-venous malformations. Hemangiomas of gastrointestinal tract are rare. Mesenteric hemangiomas are also extremely rare.We present a 25-year-old female who was admitted to the emergency room with recurrent lower gastrointestinal bleeding. An intraluminal bleeding mass inside the small intestinal segment was detected during explorative laparotomy as the cause of the recurrent lower gastrointestinal bleeding. After partial resection of small bowel segment, the histopathologic examination revealed a cavernous hemagioma of mesenteric origin.Although rare, gastrointestinal hemangioma should be thought in differential diagnosis as a cause of recurrent lower gastrointestinal bleeding.

To review the epidemiology, pathophysiology and mechanisms of irritable bowel syndrome (IBS), constipation, and diverticulosis, for the purpose of addressing these three common conditions in older adults (>65 years of age).Using a MEDLINE search, we identified original English language journal articles and reviews from 1965 to December 1998. We also selected articles published before 1965 or after 1998 that were cross-referenced or pertinent to the topics researched.The prevalence of constipation and diverticulosis is higher in older than in younger adults. Significant risk factors for constipation in older women are failure of the anorectal angle to open or excessive perineal descent, which represent disturbances of pelvic floor function and rectal evacuation. In contrast, the prevalence of IBS is no greater than in younger adults. Nevertheless, these syndromes impact on the patient's functional status and quality of life. The mechanisms resulting in these gastrointestinal syndromes are unclear. Uncoordinated colonic activity and colonic segmentation may lead to IBS and diverticulosis, respectively, and these pathophysiological findings suggest disorders of inhibitory control of neuromuscular function. The total number of neurons in the myenteric plexus is decreased, and collagen deposited in the distal colon is increased with aging in humans. Animal studies suggest that senescent colonic muscle responds less to excitatory factors in vitro, and neural injury in older animals may result from apoptosis, defects of mitochondrial metabolism, and inadequate levels or response to neurotrophins. Future investigations will reveal whether similar mechanisms underlie human disease. Currently, treatment is aimed at relief of symptoms of IBS or constipation or dealing with the complications of diverticulosis.Constipation, IBS, and diverticulosis are common problems of aging. There is a need for further systematic research of the basic mechanisms in neuromuscular dysfunction with aging, including the studies of physical characteristics of the colonic wall, pelvic floor function (particularly in women with excessive perineal descent), and neurohormonal control of motility and sensation. Insights on the pathophysiology and mechanisms of neural injury may lead to more specific treatments in the future, e.g., serotonergic agents and neurotrophins. Meanwhile, collaborations between primary care physicians, geriatricians, and gastroenterologists can optimize management of these three common conditions that significantly impact the quality of life of older adults.

The importance of patient casemix as a determinant of surgical outcome is now being recognized. The present study was undertaken in order to compare the presentation and outcomes in colorectal patients managed surgically by the same surgeon, in the same way, in different settings.Colorectal outcome data from the University Department of Surgery in Wellington and the King Faisal Specialist Hospital in Riyadh were analysed in order to determine casemix differences between the two hospitals. Data relating to the type of surgery, the surgeon, the patient's disease, the operation performed and the postoperative complications were compared. Specific colorectal clinical indicators were compared for two commonly performed operations for rectal cancer: anterior resection and abdomino-perineal resection of the rectum.Wellington patients were slightly older and there were more females. Emergency surgery was more frequent in Wellington. Left hemicolectomy, sigmoid colectomy, abscess drainage and pilonidal surgery were more common in Wellington whereas abdomino-perineal resection and anterior resection of the rectum, stoma closure, fistula surgery, seton insertion, restorative proctocolectomy and ileostomy were undertaken more frequently in Riyadh. More complex anal fistulas were managed in Riyadh. Condylomata accuminata, pilonidal abscess, anorectal abscess, rectal prolapse and diverticular disease were rarely seen in Riyadh. There were more postoperative pulmonary and cardiac complications in Wellington. Patients having anterior resection of the rectum were younger in Riyadh and there were proportionally more females. There were some obvious numerical outcome differences in postoperative atelectasis, wound infection, anastomotic leak and deep vein thrombosis rates but none of these reached statistical significance except atelectasis. In Riyadh the usual male-to-female ratio of patients undergoing abdomino-perineal resection was reversed but, again, none of the numerical outcome differences observed reached statistical significance except postoperative atelectasis and intraabdominal abscess.Although not statistically significant, the results of the present study suggest that when the same surgeon operates using the same technique in different communities, the outcomes may be different. Care should thus be taken when comparing different populations with different casemixes before definitive conclusions are made in comparative studies.

Morbidity and mortality rates are higher in elderly compared to younger patients undergoing colorectal cancer surgery. This study was undertaken to see whether this finding applied to all colorectal surgery in the elderly and if so to try to identify the determining factors.All patients undergoing colorectal surgery between 1975 and 1990 were entered into a computerized database. Patients were divided into two groups, those less than 80 years (< 80) and those 80 years and more (80+), and compared with regard to the type of surgery performed, the patient's race, the seniority of the surgeon, the patient's disease, the operation performed and the postoperative morbidity and mortality. In addition, patients undergoing major resectional surgery and patients undergoing colorectal cancer surgery were compared separately.Of 2011 admissions, 88 were for patients of 80+. The male to female admission rate was 1:0.79 in the < 80 group and 1:1.25 in the 80+ group. More surgical procedures were performed by consultants in older patients. More emergency admissions were for 80+ patients. Rectal, sigmoid and right colonic pathology was more common in the elderly. Very few elderly patients were admitted with minor anorectal problems. Rectal prolapse and colorectal cancer were the commonest causes for admission in octogenarians. There were more pulmonary and cardiovascular postoperative complications in 80+ patients. Urinary tract infections were also more common. The postoperative mortality rate was higher in older patients (7.9 vs 1.4%). Four hundred and sixty-two patients underwent major resectional surgery and 45 were 80+. Surgery for diverticular disease was more frequent in younger patients (13.4 vs 2.2%) and cancer surgery in older patients (93.3 vs 70.5%). The postoperative mortality rate was higher in the elderly (11.1 vs 3.6%). Three hundred and thirty-six major resections were for cancer and 42 were 80+. Emergency surgery was performed more commonly in the older group (38.1 vs 14.9%). The rate of advanced disease seemed to be similar in both groups. The postoperative death rate was higher in the elderly (11.9 vs 3.4%).Elderly patients were more likely to die from cardiopulmonary problems after surgical interventions than either from their primary disease or from the surgery undertaken for it. Good postoperative cardiopulmonary support should thus be provided for all such patients.

Lower gastrointestinal bleeding can be a confusing clinical conundrum, the satisfactory evaluation and management of which requires a disciplined and orderly approach. Diagnosis and management has evolved with the development of new technology such as selective mesenteric angiography and colonoscopy.This study was undertaken to review the available data in the literature and to determine the current optimum method of evaluation and management of lower gastrointestinal hemorrhage most likely to result in a successful outcome.Data available on the topic of lower gastrointestinal bleeding in the English literature were obtained via MEDLINE search and were reviewed and analyzed.The colonic origin of lower gastrointestinal hemorrhage in order of decreasing incidence is diverticulosis, inflammatory bowel disease, including ischemic and infectious colitis, colonic neoplasia, benign anorectal disease, and arteriovenous malformations. Approximately 10 to 15 percent of all cases of rectal bleeding are attributable to a cause that is proximal to the ligament of Treitz. Small intestinal sources such as arteriovenous malformations, diverticula, and neoplasia account for between 3 and 5 percent of all cases. Colonoscopy successfully identified an origin in severe hematochezia in 74 to 82 percent of cases. Mesenteric angiography has a sensitivity of 42 to 86 percent. The best method of management depends on whether hemorrhage persists, the severity of continued hemorrhage, the cumulative transfusion requirement, and the specific origin of bleeding.Lower gastrointestinal hemorrhage is a complex clinical problem that requires disciplined and sophisticated evaluation for successful management. Diverticulosis is the most common cause. Colonoscopy is the diagnostic procedure of choice both for its accuracy in localization and its therapeutic capability. Selective mesenteric angiography should be reserved for those patients in whom colonoscopy is not practical. Precise identification of the bleeding source is crucial for a successful outcome. Specific directed therapy, such as segmental colonic resection for bleeding diverticulosis, is associated with the highest success rate and the lowest morbidity. A complete review of lower gastrointestinal bleeding is contained herein.

To compare Maori with nonMaori colorectal surgical admissions to a specialised colorectal unit in a teaching hospital.All patients admitted to the colorectal service of the university department of surgery, Wellington, New Zealand between April 1975 and March 1990 have been entered into a computerised data base. Patients claiming to be Maori or of Maori descent were compared, in relation to colorectal diagnosis, type of admission and surgery and surgical complications, with those designated European or other.There were 90 Maori admissions (47 male, 43 female) and 1842 nonMaori admissions (1007 male, 835 female). The urgency of admission was similar in both groups. There were no significant differences in admission rates for obstruction, perforation, bleeding, diverticular disease, or anorectal abscess but more Maori seemed to have problems with haemorrhoids and perineal condylomata acuminata. More nonMaori were admitted with colorectal cancer. The frequencies of most major operations were similar in the two groups studied, although haemorrhoidectomy was more common in the Maori. A higher proportion of nonMaori patients had a consultant surgeon as the primary operator. The overall complication rates, with the exception of urinary tract infections were similar in both groups. One Maori patient died and there were 31 nonMaori deaths.There was no evidence that Maori had either less access to the public hospital system or that surgical colorectal diseases were more neglected. In general hospital admission rates for colorectal diseases in Maori and nonMaori were remarkably similar.