From the Guidelines
For patients presenting with lower gastrointestinal bleeding (GIB), the primary consideration is prompt assessment and stabilization, with a focus on hemodynamic stability and appropriate management based on severity, as recommended by the British Society of Gastroenterology guidelines 1. When considering lower GIB, it is essential to stratify patients as unstable or stable, using a risk assessment tool such as the Oakland score, to guide management decisions 1.
Key Considerations
- Initial management should focus on hemodynamic stabilization with IV fluids and blood transfusions if necessary, with a restrictive red blood cell transfusion threshold of 70 g/L in clinically stable patients without cardiovascular disease 1.
- Diagnostic evaluation typically includes colonoscopy within 24 hours of presentation, allowing for both diagnosis and potential therapeutic intervention, with adequate bowel preparation being essential for proper visualization.
- Common causes of lower GIB include diverticular bleeding, angiodysplasia, hemorrhoids, and inflammatory bowel disease, with approximately 75% of episodes due to diverticulosis stopping spontaneously 1.
- For active bleeding, endoscopic interventions such as epinephrine injection, thermal coagulation, or clip placement may be used, with angiography with embolization or surgery considered if endoscopic management fails.
Management Approach
- Patients with minor self-terminating bleeds can be discharged for urgent outpatient investigation, while those with major bleeds should be admitted to hospital for colonoscopy 1.
- Haemodynamically unstable patients or those with suspected active bleeding should undergo CT angiography to localize the site of blood loss, followed by catheter angiography with embolization if necessary, with a goal of performing this within 60 minutes in centers with 24/7 interventional radiology services 1.
- Medications such as tranexamic acid may be considered for acute bleeding, and addressing underlying causes such as NSAIDs or anticoagulants is crucial, with anticoagulation reversal recommended in cases of unstable gastrointestinal haemorrhage 1.
From the Research
Considerations for Lower GIB
- Assessing various clinical factors, including comorbidities, medication use, presenting symptoms, vital signs, and laboratory data is useful for risk stratification of severe LGIB, and for discriminating upper gastrointestinal bleeding 2.
- Early timing of colonoscopy had the possibility of improving identification of the bleeding source, and the rate of endoscopic intervention, compared with elective colonoscopy 2.
- Contrast-enhanced computed tomography before colonoscopy may help identify stigmata of recent hemorrhage on colonoscopy, particularly in patients who can be examined immediately after the last hematochezia 2.
- How to deal with nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents after hemostasis should be carefully considered because of the risk of rebleeding and thromboembolic events 2.
- In general, aspirin as primary prophylaxis for cardiovascular events and NSAIDs were suggested to be discontinued after LGIB 2.
- Angiography identifies a presumptive cause of bleeding in 49 percent of patients, and identifies the site of bleeding in 86 percent of the patients with active bleeding, thus allowing segmental colectomy 3.
- Documentation of angiodysplasia in a patient with lower gastrointestinal bleeding is presumptive evidence for the site of bleeding 3.
- Goals of care aim to prevent end-organ injury, manage comorbid illnesses, identify the source of bleeding, stop continued bleeding, support oxygen carrying capacity, and prevent rebleeding 4.