Management of Lower Gastrointestinal Bleeding in Patients with End-Stage Renal Disease
Introduction to Lower Gastrointestinal Bleeding
- The American Gastroenterological Association recommends colonoscopy as the first-line investigation for lower gastrointestinal bleeding (LGIB) in hemodynamically stable patients after resuscitation 1, 2
- For hemodynamically unstable patients with LGIB, CT angiography should be performed immediately to localize bleeding before any intervention 3, 1, 2
Diagnostic Approach
- The American College of Radiology suggests CT angiography of the abdomen and pelvis to localize bleeding source, given shock index >1 3, 1, 2
- Upper endoscopy should be performed to rule out upper GI source in patients with hemodynamic instability 1, 2
Management of Coagulopathy
- The American Gastroenterological Association recommends correcting coagulopathy immediately by transfusing fresh frozen plasma for INR >1.5 and platelets for platelets <50,000/µL 1
- Aggressive platelet transfusion should be maintained to keep platelet count >50 × 10⁹/L during active bleeding 1
Management of Sepsis
- Broad-spectrum antibiotics (vancomycin + meropenem) should be continued for hospital-acquired pneumonia and catheter-related bloodstream infection 1
- Empiric antifungal therapy (fluconazole or echinocandin) should be started earlier in patients with a history of catheter-related bloodstream infection and persistent sepsis 1
Management of Heart Failure
- Careful fluid balance should be maintained in patients with heart failure with preserved ejection fraction (HFpEF) and elevated NT-proBNP 1
- Empagliflozin should be continued in patients with HFpEF 1
Key Learning Points
- Shock index >1 on admission is a predictor of poor outcome in patients with LGIB 4, 1
- Procalcitonin >2 ng/mL indicates severe sepsis and is a predictor of poor outcome 1
- Severe thrombocytopenia (<20 × 10⁹/L) with ongoing bleeding is a predictor of poor outcome 1
- Multiple comorbidities, including end-stage renal disease, heart failure, recent myocardial infarction, hospital-acquired pneumonia, and fungemia, are predictors of poor outcome 1