Management of Lower Gastrointestinal Bleeding

General Management

• Immediate evaluation and resuscitation are critical for patients with gastrointestinal bleeding, prioritizing hemodynamic stabilization before diagnostic procedures, as recommended by the American College of Physicians 1
• Assess shock index (heart rate divided by systolic blood pressure) to determine stability, with a shock index >1 indicating instability, according to the European Society of Gastrointestinal Endoscopy 2
• Establish two large-bore IV access points for fluid and blood administration 3
• Crystalloid fluid resuscitation should be initiated concurrently with blood transfusion, but crystalloid alone is insufficient when hemoglobin is low with signs of compromised tissue perfusion 3
• Maintain mean arterial pressure >65 mmHg while avoiding fluid overload, as recommended by the World Journal of Emergency Surgery guidelines 4
• Correct coagulopathy if present, as recommended by the World Journal of Emergency Surgery guidelines 4
• Consider nasogastric tube placement in selected patients as findings may have prognostic value, as recommended by the American College of Physicians 1
• If very early endoscopy is planned, orogastric or nasogastric lavage may help clear the stomach of blood and clots, according to the American Society for Gastrointestinal Endoscopy 1

Diagnostic Evaluation

• Upper Endoscopy (EGD) should be performed first to rule out upper GI source, as up to 8% of patients presenting with hematochezia may have an upper GI source 4
• Upper and lower GI endoscopy are the initial diagnostic procedures of choice for stable patients with GI bleeding, including sigmoidoscopy to evaluate the distal colon and esophagogastroduodenoscopy (EGD) to rule out upper GI bleeding, as recommended by the World Journal of Emergency Surgery and the National Comprehensive Cancer Network 5, 6
• CT Angiography (CTA) can detect bleeding rates as low as 0.3 mL/min, providing information on bleeding location and potential culprit lesions, with a high diagnostic yield for detecting bleeding at rates of 0.3-1.0 mL/min 7, 5
• The following table summarizes the diagnostic yield of different imaging modalities:

• CT Enterography (CTE) is the first-line imaging test for suspected small bowel bleeding in stable patients, particularly when patients are at increased risk for video capsule retention, as recommended by the Radiology guidelines 8

Blood Transfusion Strategy

• Blood transfusion is indicated when hemoglobin is less than 10 g/dL in acute bleeding, with a target hemoglobin level of >7g/dL, or >9g/dL in patients with cardiovascular disease 3, 5
• Avoid overaggressive blood transfusion, as a restrictive transfusion strategy (Hb >7 g/dL) improves outcomes in most patients, as recommended by the World Journal of Emergency Surgery guidelines 4
• The American College of Gastroenterology recommends using restrictive RBC thresholds (Hb trigger 70 g/L and target 70-90 g/L) for clinically stable patients, and a higher threshold (Hb trigger 80 g/L and target 100 g/L) for patients with cardiovascular disease 2

Coagulation Management

• Anticoagulant therapy should be interrupted at presentation, and warfarin should be reversed with prothrombin complex concentrate and vitamin K for patients with severe hemorrhage, as recommended by the American College of Gastroenterology 2
• Antiplatelet agents should be temporarily withheld in acute LGIB, despite potential cardiovascular risks 2
• Oral direct anticoagulants should be considered for restart no more than 7 days after bleeding, with a moderate level of evidence 2
• Consider reversal agents (idarucizumab or andexanet) for life-threatening hemorrhage on direct oral anticoagulants (DOACs), as recommended by the American Heart Association 2

Colonoscopy

• Early colonoscopy (within 12 hours) is safe and effective, improving diagnostic yield and potentially reducing hospital stay, according to the American Gastroenterological Association 9
• The American Gastroenterological Association recommends considering colonic purge with PEG-based solution (5-8L) to clear the bowel for better visualization 9
• Angiodysplasia can be treated with contact thermal probes or argon plasma coagulation, according to the American Gastroenterological Association 9
• Diverticular bleeding can be treated with endoscopic hemostasis with clips or thermal therapy, according to the American College of Gastroenterology 2

Embolization

• Technical success rates of embolization are high (93-100%), according to the American College of Gastroenterology 2
• Complications of embolization include bowel ischemia (7-24%) and rebleeding (10-50% short-term), according to the American College of Gastroenterology 2

Surgery

• Emergency subtotal colectomy is effective for unlocalised massive LGIB but has high morbidity and mortality, according to the American College of Gastroenterology 2
• Surgery should ideally be performed by colorectal surgeons who can perform on-table colonoscopy, according to the American College of Gastroenterology 2
• Pre-operative localization of the bleeding site is essential to exclude upper GI or anorectal bleeding and to plan appropriate surgical strategy if needed, as stated by the World Journal of Emergency Surgery 5

Follow-up and Prevention

• Gastroenterology follow-up should be scheduled within 2 weeks if discharged, and cardiology follow-up should be arranged to assess stent status and optimize antiplatelet regimen, according to the American College of Cardiology and American Gastroenterological Association 10, 2
• Screening for H. pylori and eradication if positive is necessary, as suggested by the American Gastroenterological Association 2
• Iron supplementation can be effective for patients discharged with anemia, with a response rate of 80-90%, as recommended by the American Gastroenterological Association 9, 2
• The following table summarizes the differences between acute and chronic bleeding: