What is the treatment plan for a lower gastrointestinal (GI) bleed?

From the Guidelines

The treatment plan for a lower gastrointestinal (GI) bleed should prioritize stabilizing the patient, identifying the source of bleeding, and providing appropriate interventions, with a focus on colonoscopy as the gold standard for diagnosis and potential treatment, as recommended by the British Society of Gastroenterology guidelines 1.

Initial Assessment and Stabilization

The initial assessment should include vital sign monitoring and establishment of IV access with two large-bore catheters (16-18 gauge) to ensure hemodynamic stability. For unstable patients with significant bleeding, crystalloid fluids should be administered, and blood transfusion considered to maintain hemoglobin above 7 g/dL (or 9 g/dL in patients with cardiovascular disease) 1.

• Discontinue anticoagulants and antiplatelet medications if possible.
• Diagnostic evaluation includes complete blood count, coagulation studies, and colonoscopy.

Diagnostic Evaluation and Intervention

For active bleeding, colonoscopy should be performed within 24 hours after adequate bowel preparation, as recommended by the British Society of Gastroenterology guidelines 1.

• Angiography with embolization may be considered if colonoscopy cannot identify the source or if bleeding is too severe for endoscopic intervention.
• For diverticular bleeding, endoscopic hemostasis with clips or thermal coagulation is effective, as noted in the ACR Appropriateness Criteria 2.
• Angiodysplasia can be treated with argon plasma coagulation.
• For inflammatory bowel disease-related bleeding, initiate corticosteroids (prednisone 40-60 mg daily) and consider biologics like infliximab.

Surgical Intervention

Surgical intervention is reserved for persistent bleeding unresponsive to other treatments or for specific conditions like segmental colitis, as recommended by the British Society of Gastroenterology guidelines 1 and supported by earlier studies 3.

• No patient should proceed to emergency laparotomy unless every effort has been made to localise bleeding by radiological and/or endoscopic modalities, except under exceptional circumstances 1.

Preventive Measures

After acute management, address underlying causes and implement preventive measures, including optimizing management of conditions like diverticulosis or inflammatory bowel disease, and carefully weighing risks and benefits before restarting anticoagulation, as noted in the guidelines 1.

• Restrictive RBC thresholds (Hb trigger 70 g/L and a Hb concentration target of 70–90 g/L after transfusion) should be used, unless the patient has a history of cardiovascular disease, in which case a trigger of 80 g/L and a target of 100 g/L should be used 1.

From the Research

Lower GI Bleed Treatment Plan

• The treatment plan for lower GI bleed involves initial assessment of hemodynamic status and intravascular volume resuscitation as needed 4.
• Risk stratification based on clinical parameters should be performed to distinguish patients at high- and low-risk of adverse outcomes 4, 5.
• Colonoscopy is the initial diagnostic procedure of choice and should be performed within 24 hours of patient presentation after adequate colon preparation 4.
• Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding, including active bleeding, non-bleeding visible vessel, or adherent clot 4.
• The choice of endoscopic hemostasis modality (mechanical, thermal, injection, or combination) is guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience 4.

Management of Bleeding

• Repeat colonoscopy with endoscopic hemostasis should be considered for patients with evidence of recurrent bleeding 4.
• Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy 4, 5.
• Strategies to prevent recurrent bleeding should be considered, including avoidance of nonsteroidal anti-inflammatory drug use in patients with a history of acute lower GI bleeding 4.

Medication Management

• Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding, with the exact timing depending on the severity of bleeding and the risk of a thromboembolic event 4.
• The management of antithrombotic medications after hospital discharge should be individualized, with consideration of the risk of recurrent bleeding and thromboembolic events 5.