Lower Gastrointestinal Bleeding Guidelines

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

Clinical practice recommendations on the diagnosis and management of acute lower gastrointestinal bleeding (LGIB) were published in February 2019 by the British Society of Gastroenterology. [77]

Patients can be discharged for urgent outpatient investigation if they present with a minor, self-terminating bleed (eg, individuals with an Oakland score ≤8 points) if no other indications for hospital admission exist.

In the context of a major bleed, patients should obtain hospital admission for colonoscopy on the next available list.

Prior to the planning of endoscopic or radiologic therapy, localization of the site of blood loss can be most quickly, and least invasively, achieved via computed tomography (CT) angiography, in patients who are hemodynamically unstable or have a shock index (heart rate/systolic blood pressure) of greater than 1 after initial resuscitation and/or in whom active bleeding is suspected.

If, in hemodynamic instability–associated LGIB, initial CT angiography turns up no bleeding source, an upper endoscopy should be performed immediately, since such LGIBs may indicate the presence of an upper GI bleeding source. Gastroscopy may be the first investigation when patient stabilization is achieved after initial resuscitation.

If CT angiography is positive, the patient should, when indicated and as soon as possible, undergo catheter angiography with a view to embolization, to achieve maximum chance of success. Centers with a 24/7 interventional radiology service should be capable of performing catheter angiography for hemodynamically unstable patients within 60 minutes of admission.

Patients should not, except under exceptional circumstances, proceed to emergency laparotomy unless an exhaustive effort has been made, via radiologic and/or endoscopic modalities, to localize bleeding.

Restrictive red blood cell (RBC) thresholds (a hemoglobin [Hb] trigger of 70 g/L and an Hb concentration target of 70-90 g/L after transfusion) are appropriate for clinically stable patients who need RBC transfusion. In patients with a history of cardiovascular disease, however, the trigger and target should be 80 g/L and 100 g/L, respectively.

Patients with a low thrombotic risk should be restarted on warfarin therapy at 7 days posthemorrhage.

Aspirin therapy for secondary prevention of cardiovascular events should not be routinely stopped. If it is ceased, recommencement should occur as soon as the patient achieves hemostasis.

Routine cessation of dual antiplatelet therapy with a P2Y12 receptor antagonist and aspirin is not recommended in patients with coronary stents in situ, and a cardiologist should be involved in management. If administration of the P2Y12 receptor antagonist is interrupted in the context of unstable hemorrhage, aspirin therapy should be continued. Treatment with the P2Y12 receptor antagonist should recommence within 5 days.

Direct oral anticoagulant therapy should be interrupted at presentation. Treatment with inhibitors such as idarucizumab or andexanet should be considered for life-threatening hemorrhage in patients who have been taking direct oral anticoagulants.