What is the management approach for a patient with a lower gastrointestinal (GI) bleed?

From the Guidelines

The management of a lower gastrointestinal (GI) bleed should prioritize patient stabilization, followed by diagnosis and definitive treatment, with a strong recommendation for colonoscopy as the first-line procedure for most lower GI bleeds, as suggested by the British Society of Gastroenterology guidelines 1. The approach to managing a lower GI bleed involves assessing hemodynamic stability with vital signs and establishing large-bore IV access for fluid resuscitation using crystalloids like normal saline or lactated Ringer's solution.

• Blood transfusion with packed red blood cells is indicated for hemoglobin below 7 g/dL or for unstable patients, with restrictive RBC thresholds (Hb trigger 70 g/L and a Hb concentration target of 70–90 g/L after transfusion) recommended for clinically stable patients who may need red blood cell (RBC) transfusion 1.
• Correcting any coagulopathy with fresh frozen plasma, platelets, or reversal agents as needed is also crucial. After stabilization, a diagnostic evaluation including a focused history, physical examination, and laboratory tests (complete blood count, coagulation profile, and type and cross-match) should be performed.
• Endoscopic evaluation, specifically colonoscopy, is the cornerstone of diagnosis and treatment for most lower GI bleeds, with a strong recommendation for its use in patients with a major bleed 1.
• CT angiography should be considered for active, brisk bleeding when endoscopy is not immediately available or feasible, particularly if a patient is haemodynamically unstable or has a shock index (heart rate/systolic BP) of >1 after initial resuscitation and/or active bleeding is suspected 1. Treatment depends on the cause but may include endoscopic interventions (clipping, thermal coagulation, or injection therapy), angiographic embolization for arterial bleeding, or surgery for uncontrolled bleeding.
• Specific management of underlying causes like diverticular disease, angiodysplasia, or inflammatory bowel disease should follow once the acute bleeding is controlled, with the goal of minimizing morbidity, mortality, and improving quality of life. Close monitoring in an appropriate setting (ICU for unstable patients) with serial hemoglobin measurements is essential throughout the management process.
• The use of clinical prognostic criteria, such as the BLEED classification system, can help distinguish patients with a high and a low risk of recurrent hemorrhage, although its predictive accuracy is lower compared to other models like artificial neural networks (ANN) 1.

From the Research

Management Approach for Lower GI Bleed

The management approach for a patient with a lower gastrointestinal (GI) bleed involves several key steps, including:

• Initial assessment of the patient's condition, including history of co-morbidities and medications that promote bleeding, hemodynamic parameters, physical examination, and laboratory markers 2
• Use of a risk score to aid in clinician judgment, but not replace it, to determine the severity of the bleed and guide management decisions 2
• Consideration of a restrictive red blood cell transfusion strategy in hemodynamically stable patients with no history of cardiovascular disease, with a hemoglobin threshold of ≤7 g/dL prompting transfusion 2
• Performance of colonoscopy during hospital stay for patients with major acute lower GI bleeding, as there is no high-quality evidence that early colonoscopy influences patient outcomes 2
• Use of computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding in patients with hemodynamic instability and suspected ongoing bleeding 2

Medication Management

Medication management is also an important aspect of treating lower GI bleed, including:

• Withholding vitamin K antagonists in patients with major lower GI bleeding and correcting coagulopathy according to the severity of bleeding and thrombotic risk 2
• Temporarily withholding direct oral anticoagulants at presentation in patients with major lower GI bleeding 2
• Not withholding aspirin in patients taking low-dose aspirin for secondary cardiovascular prevention, and resuming it within 5 days or earlier if hemostasis is achieved or there is no further evidence of bleeding 2
• Not routinely discontinuing dual antiplatelet therapy before cardiology consultation, but considering continuation or temporary interruption according to the severity of bleeding and ischemic risk 2

Risk Stratification and Diagnostic Testing

Risk stratification and diagnostic testing are crucial in managing lower GI bleed, including:

• Use of risk stratification tools to identify patients at low risk of hospital-based intervention 3
• Performance of nonurgent colonoscopy in most patients requiring inpatient colonoscopy, as urgent colonoscopy within 24 hours of presentation has not been shown to improve clinical outcomes 3
• Use of computed tomography angiography in patients with severe lower GI bleeding to locate the site of bleeding 3