From the Guidelines
For patients presenting with lower gastrointestinal bleeding (GIB), immediate assessment and stabilization are crucial, with a focus on hemodynamic stabilization through IV fluid resuscitation and blood transfusions if hemoglobin is below 7-8 g/dL, as recommended by the British Society of Gastroenterology guidelines 1. When considering the management of lower GIB, it is essential to stratify patients as unstable or stable, using a risk assessment tool such as the Oakland score, as suggested by the guidelines 1.
Key Considerations
- Stable 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.
- For patients with haemodynamic instability or active bleeding, CT angiography is recommended to localize the site of blood loss before planning endoscopic or radiological therapy 1.
- The use of restrictive red blood cell transfusion thresholds, with a hemoglobin trigger of 70 g/L and a target of 70-90 g/L after transfusion, is recommended for clinically stable patients who may need red blood cell transfusion 1.
- Discontinuing medications that increase bleeding risk, such as anticoagulants, is also crucial in the management of lower GIB, as highlighted in the guidelines 1.
Diagnostic Evaluation
- A thorough history and physical examination, focusing on bleeding characteristics, medication use, and comorbidities, is essential in the diagnostic evaluation of lower GIB.
- Complete blood count, coagulation studies, and colonoscopy within 24 hours of presentation are recommended as the primary diagnostic tools, with CT angiography considered for active bleeding if colonoscopy is inconclusive 1.
Treatment
- Treatment of lower GIB depends on the cause, with endoscopic hemostasis with clips or thermal therapy recommended for diverticular bleeding, argon plasma coagulation for angiodysplasias, and anti-inflammatory medications for inflammatory bowel disease 1.
- Discontinuing medications that increase bleeding risk and rectal packing for anorectal sources may also be necessary, with surgery reserved for persistent bleeding unresponsive to other interventions 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
- Treatment options ranging from minimally invasive techniques to open surgery are explored for lower gastrointestinal bleeding 5