Management of acute lower GI bleeding-ACG Guideline

The American College of Gastroenterology has released its guidelines on Management of acute acute overt lower gastrointestinal bleeding which have been published in The American Journal of Gastroenterology.

Acute overt lower gastrointestinal bleeding (LGIB) accounts for ~20% of all cases of gastrointestinal (GI) bleeding, usually leads to hospital admission . Although most patients with acute LGIB stop bleeding spontaneously and have favourable outcomes, morbidity and mortality are increased in older patients and those with comorbid medical conditions.

Major Recommendations

• Evaluation and Risk Stratification

1. A focused history, physical examination, and laboratory evaluation should be obtained at the time of patient presentation to assess the severity of bleeding and its possible location and etiology. Initial patient assessment and hemodynamic resuscitation should be performed simultaneously (Strong recommendation, very-low-quality evidence).


2. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal bleeding (UGIB) source, and an upper endoscopy should be performed. A nasogastric aspirate/lavage may be used to assess a possible upper gastrointestinal (GI) source if suspicion of UGIB is moderate (Strong recommendation, low-quality evidence).


3. Risk assessment and stratification should be performed to help distinguish patients at high and low risks of adverse outcomes and assist in patient triage including the timing of colonoscopy and the level of care (Conditional recommendation, low-quality evidence).

• Hemodynamic Resuscitation

1. Patients with hemodynamic instability and/or suspected ongoing bleeding should receive intravenous fluid resuscitation with the goal of normalization of blood pressure and heart rate prior to endoscopic evaluation/intervention (Strong recommendation, very-low-quality evidence).


2. Packed red blood cells should be transfused to maintain the hemoglobin above 7 g/dl. A threshold of 9 g/dl should be considered in patients with massive bleeding, significant comorbid illness (especially cardiovascular ischemia), or a possible delay in receiving therapeutic interventions (Conditional recommendations, low-quality evidence).

• Management of Anticoagulant Medications

1. Endoscopic hemostasis may be considered in patients with an international normalized ratio (INR) of 1.5–2.5 before or concomitant with the administration of reversal agents. Reversal agents should be considered before endoscopy in patients with an INR >2.5 (Conditional recommendation, very-low-quality evidence).


2. Platelet transfusion should be considered to maintain a platelet count of 50×10/l in patients with severe bleeding and those requiring endoscopic hemostasis (Conditional recommendation, very-low-quality evidence).


3. Platelet and plasma transfusions should be considered in patients who receive massive red blood cell transfusions (Conditional recommendation, very-low-quality evidence).


4. In patients on anticoagulant agents, a multidisciplinary approach (e.g., hematology, cardiology, neurology, and gastroenterology) should be used when deciding whether to discontinue medications or use reversal agents to balance the risk of ongoing bleeding with the risk of thromboembolic events (Strong recommendation, very-low-quality evidence).

• Colonoscopy as a Diagnostic Tool

1. Colonoscopy should be the initial diagnostic procedure for nearly all patients presenting with acute lower gastrointestinal bleeding (LGIB) (Strong recommendation, low-quality evidence).


2. The colonic mucosa should be carefully inspected during both colonoscope insertion and withdrawal, with aggressive attempts made to wash residual stool and blood in order to identify the bleeding site. The endoscopist should also intubate the terminal ileum to rule out proximal blood suggestive of a small bowel lesion (Conditional recommendation, very-low-quality evidence).

• Bowel Preparation

1. Once the patient is hemodynamically stable, colonoscopy should be performed after adequate colon cleansing. Four to six liters of a polyethylene glycol (PEG)-based solution or the equivalent should be administered over 3 to 4 h until the rectal effluent is clear of blood and stool. Unprepped colonoscopy/sigmoidoscopy is not recommended (Strong recommendation, low-quality evidence).


2. A nasogastric tube can be considered to facilitate colon preparation in high-risk patients with ongoing bleeding who are intolerant to oral intake and are at low risk of aspiration (Conditional recommendation, low-quality evidence).

• Timing of Colonoscopy

1. In patients with high-risk clinical features and signs or symptoms of ongoing bleeding, a rapid bowel purge should be initiated following hemodynamic resuscitation and a colonoscopy performed within 24 h of patient presentation after adequate colon preparation to potentially improve diagnostic and therapeutic yield (Conditional recommendation, low-quality evidence).


2. In patients without high-risk clinical features or serious comorbid disease or those with high-risk clinical features without signs or symptoms of ongoing bleeding, colonoscopy should be performed next available after a colon purge (Conditional recommendation, low-quality evidence).

• Endoscopic Hemostasis Therapy

1. Endoscopic therapy should be provided to patients with high-risk endoscopic stigmata of bleeding: active bleeding (spurting and oozing); non-bleeding visible vessel; or adherent clot (Strong recommendation, low-quality evidence).


2. Diverticular bleeding: through-the-scope endoscopic clips are recommended as clips may be safer in the colon than contact thermal therapy and are generally easier to perform than band ligation, particularly for right-sided colon lesions (Conditional recommendation, low-quality evidence).


3. Angioectasia bleeding: noncontact thermal therapy using argon plasma coagulation is recommended (Conditional recommendation, low-quality evidence).


4. Post-polypectomy bleeding: mechanical (clip) or contact thermal endotherapy, with or without the combined use of dilute epinephrine injection, is recommended (Strong recommendation, low-quality evidence).


5. Epinephrine injection therapy (1:10,000 or 1:20,000 dilution with saline) can be used to gain initial control of an active bleeding lesion and improve visualization but should be used in combination with a second hemostasis modality including mechanical or contact thermal therapy to achieve definitive hemostasis (Strong recommendation, very-low-quality evidence).