From the Guidelines
Management of acute lower GI bleeding in the emergency department should prioritize rapid assessment and stabilization, with a focus on hemodynamic status and timely intervention to control bleeding and prevent complications. The initial approach should involve establishing two large-bore IV lines for fluid resuscitation with crystalloids, and administering blood products as needed to target a hemoglobin level of at least 7 g/dL (or 9 g/dL in patients with cardiovascular disease) 1. Correcting coagulopathy with fresh frozen plasma, platelets, or prothrombin complex concentrate is also crucial, as is discontinuing anticoagulants and antiplatelets if possible, and considering reversal agents when appropriate 1. After stabilization, arranging for urgent colonoscopy within 24 hours is recommended, as this is both diagnostic and potentially therapeutic 1. Consideration of CT angiography for patients with active, brisk bleeding to identify the source and potentially guide interventional radiology procedures is also important, particularly for hemodynamically unstable patients or those who have required significant blood transfusions 1. Specific treatments may include endoscopic interventions, angiographic embolization for ongoing bleeding, or surgical intervention for unstable patients not responding to other measures, with the goal of balancing rapid stabilization with diagnostic precision to effectively control bleeding and prevent complications 1. Key aspects of management include:
- Rapid evaluation of hemodynamic status
- Fluid resuscitation and blood product administration as needed
- Correction of coagulopathy
- Discontinuation of anticoagulants and antiplatelets
- Urgent colonoscopy within 24 hours
- Consideration of CT angiography for active, brisk bleeding
- Endoscopic, angiographic, or surgical interventions as necessary to control bleeding and prevent complications.
From the Research
Initial Assessment and Management
- The initial assessment of patients presenting with acute lower gastrointestinal bleeding should include a history of co-morbidities and medications that promote bleeding, hemodynamic parameters, physical examination, and laboratory markers 2.
- A risk score can be used to aid, but should not replace, clinician judgment in assessing patients with acute lower gastrointestinal bleeding 2.
- In patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation 2.
Transfusion Strategy
- A restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion, is recommended in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease 2.
- In hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion, is recommended 2.
Diagnostic Testing
- Colonoscopy should be performed sometime during the hospital stay in patients with major acute lower gastrointestinal bleeding, as there is no high-quality evidence that early colonoscopy influences patient outcomes 2.
- Computed tomography angiography before endoscopic or radiologic treatment can help locate the site of bleeding in patients with hemodynamic instability and suspected ongoing bleeding 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 3.
Medication Management
- Vitamin K antagonists should be withheld in patients with major lower gastrointestinal bleeding, and coagulopathy should be corrected according to the severity of bleeding and thrombotic risk 2.
- Direct oral anticoagulants should be temporarily withheld at presentation in patients with major lower gastrointestinal bleeding 2.
- Aspirin should not be withheld in patients taking low-dose aspirin for secondary cardiovascular prevention, and should be resumed within 5 days or earlier if hemostasis is achieved or there is no further evidence of bleeding 2.
- Dual antiplatelet therapy can be continued or temporarily interrupted according to the severity of bleeding and ischemic risk, and should be restarted within 5 days if still indicated 2.
Other Considerations
- Appropriate decision-making is needed to initially manage acute lower gastrointestinal bleeding, including emergency hospitalization, timing of colonoscopy, and medication use 3.
- Managing acute lower gastrointestinal bleeding based on risk stratification and clinical factors can improve clinical outcomes 3, 4.
- Surgical intervention should be considered only for patients with uncontrolled severe bleeding or multiple ineffective nonsurgical treatment attempts 5.