Guideline sources The following summarized guidelines for the evaluation and management of lower gastrointestinal bleeding (LGIB) are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2023; 2016), the European Society of Gastrointestinal Endoscopy (ESGE 2023), the American College of Gastroenterology (ACG/CAG 2022), the British Society for Haematology (BSH 2022), the European Society of Intensive Care Medicine (ESICM 2021), the British Society of Gastroenterology (BSG 2019), and the American Society for Gastrointestinal Endoscopy (ASGE 2017; 2014). 1 2 3 4 5 6 7 8 9 10 10 11 11 12 Definition LGIB is defined as gastrointestinal bleeding originating distal to the ileocecal valve, which includes the colon, rectum and anus. 10 https://web.pathway.md/diseases/recylSZ8CuaSh0o20 1/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway Epidemiology Notable causes of LGIB include diverticulosis (42.5%), ischemic colitis (12.5%), hemorrhoids (12.5%), colorectal polyps or neoplasms (8.5%), angioectasias (7.5%), postpolypectomy bleeding (4.5%), IBD (4%), infectious colitis (3.5%), stercoral ulceration (<2.5%), colorectal varices (<1.5%), radiation proctopathy (<1%), NSAID-inducted colopathy (<1%), and Dieulafoy's lesions (<1%). 10 Pathophysiology In the United States, the age- and sex-adjusted incidence of hospitalization for LGIB is estimated at 35.7 cases per 100,000 person-years. 11 Disease course LGIB classically manifests as hematochezia (maroon or red blood passed through the rectum). Uncommonly, bleeding from the right colon may present with melena. If bleeding is severe, manifestations of hemorrhagic shock may be present. 12 Prognosis and risk of recurrence LGIB is associated with an estimated bleeding-related mortality of 1.1% (95% CI, 0.6-1.8%), and an overall rebleeding rate of 13.5% (95% CI, 11.8-15.5%). 11 Calculator Oakland score for safe discharg Guidelines 1. Classification and risk stratification Risk stratification: As per ACG 2023 guidelines, consider using risk stratification tools (such as the Oakland score 8) to identify low-risk patients with LGIB being appropriate for early discharge and outpatient diagnostic evaluation. Use risk scores to supplement but not replace clinician judgment. C As per BSG 2019 guidelines, consider stratifying patients presenting with LGIB as unstable or stable (unstable defined as a shock index > 1). Categorize stable patients then as major or minor using a risk assessment tool, such as the Oakland score. C 2. Diagnostic investigations Clinical assessment: https://web.pathway.md/diseases/recylSZ8CuaSh0o20 2/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway As per ACG 2016 guidelines, elicit a focused history, perform a physical examination, and obtain laboratory evaluation at the time of patient presentation to assess the severity of bleeding and its possible location and etiology. Obtain initial patient assessment and perform hemodynamic resuscitation simultaneously. B As per ASGE 2014 guidelines, consider performing a DRE and flexible sigmoidoscopy as sufficient evaluation in younger patients with chronic intermittent scant hematochezia without alarm symptoms. C Computed tomography angiography: As per ACG 2023 guidelines: Consider obtaining CT angiography as the initial diagnostic evaluation in patients with ongoing hemodynamically significant hematochezia, recognizing that CT angiography is of yield in patients with minor LGIB and in patients with clinically subsided bleeding. C Refer patients with extravasation on CT angiography promptly to interventional radiology for transcatheter arteriography and possible embolization. B As per BSG 2019 guidelines, obtain CT angiography to localize the bleeding site before planning endoscopic or radiological therapy in hemodynamically unstable patients or patients with a shock index of > 1 after initial resuscitation and/or suspected active bleeding. B As per ASGE 2017 guidelines, consider obtaining CT angiography for localization of the bleeding site and to guide the timing of angiography in hemodynamically stable patients with suspected active small bowel bleeding. C Computed tomography or magnetic resonance enterography: As per ASGE 2023 guidelines, consider obtaining dedicated small bowel cross-sectional imaging in patients with suspected small bowel bleeding, including when small bowel capsule endoscopy is unavailable or contraindicated. C As per ASGE 2017 guidelines, consider obtaining multiphase CT or MR enterography in patients with obscure bleeding and suspected small bowel neoplasms. C Red blood cell scan: consider obtaining a RBC scan for localization of the bleeding site and to guide the timing of angiography in hemodynamically stable patients with suspected active small bowel bleeding. C 3. Diagnostic procedures Bowel preparation: perform rapid bowel purge following hemodynamic resuscitation in patients with high-risk clinical features and signs or symptoms of ongoing bleeding, and perform colonoscopy within 24 hours of patient presentation. B Show 3 more Lower gastrointestinal endoscopy: As per ACG 2023 guidelines, perform colonoscopy in most patients hospitalized with LGIB because of its value in detecting a source of bleeding. B Show 2 more https://web.pathway.md/diseases/recylSZ8CuaSh0o20 3/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway As per BSG 2019 guidelines, admit patients with major LGIB to hospital for colonoscopy on the next available list. B As per ASGE 2017 guidelines, perform repeated lower gastrointestinal endoscopy in patients with signs or symptoms consistent with lower gastrointestinal sources of bleeding before small bowel evaluation. B As per ASGE 2014 guidelines, perform lower gastrointestinal endoscopy in patients with occult gastrointestinal bleeding. A Show 4 more Upper gastrointestinal endoscopy: As per BSG 2019 guidelines: Perform an upper gastrointestinal endoscopy to assess for an upper gastrointestinal bleeding source immediately after a negative initial CT angiography in patients with hemodynamic instability. B Consider performing upper gastrointestinal endoscopy as the first investigation in patients stabilizing after initial resuscitation. B As per ASGE 2017 guidelines, perform repeated upper gastrointestinal endoscopy before small bowel evaluation in patients with signs or symptoms consistent with upper gastrointestinal sources of bleeding. B As per ACG 2016 guidelines: Perform an upper gastrointestinal endoscopy in patients with hematochezia associated with hemodynamic instability, as it may indicate an upper gastrointestinal bleeding source. B Consider performing a nasogastric aspirate/lavage to assess for a possible upper gastrointestinal source in patients with a moderate suspicion of upper gastrointestinal bleeding. B As per ASGE 2014 guidelines, perform an upper gastrointestinal endoscopy in patients with occult gastrointestinal bleeding if a bleeding source is not identified in the colon, especially in patients with upper gastrointestinal symptoms, iron deficiency anemia, or NSAID use. B Show 2 more Video capsule endoscopy: As per ESGE 2023 guidelines: Perform small bowel capsule endoscopy as first-line evaluation in patients with suspected small bowel bleeding, before consideration of other endoscopic and radiological diagnostic tests, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small bowel mucosa. B Perform small bowel capsule endoscopy in patients with overt suspected small bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield. A As per ASGE 2017 guidelines, consider performing video capsule endoscopy as the initial investigation in patients with overt or occult small bowel bleeding. C https://web.pathway.md/diseases/recylSZ8CuaSh0o20 4/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway Small bowel endoscopy: As per ESGE 2023 guidelines: Consider performing device-assisted enteroscopy as an alternative first-line test in selected cases, depending on the clinical scenario and local availability, given that it allows diagnosis and treatment in the same procedure. C Perform device-assisted enteroscopy in patients with overt suspected small bowel bleeding, optimally within 48-72 hours after the bleeding episode. A As per ASGE 2017 guidelines, perform push enteroscopy if within reach or device-assisted enteroscopy following positive video capsule endoscopy. B Show 2 more As per ASGE 2014 guidelines, consider obtaining small bowel evaluation after negative upper and lower gastrointestinal endoscopy results in patients with occult gastrointestinal bleeding with persistent anemia. C 4. Medical management Setting of care: Admit patients with major LGIB to the hospital for colonoscopy on the next available list. B Consider discharging patients presenting with minor self-terminating bleeding (such as those with an Oakland score 8 points), in the absence of other indications for hospital admission, for urgent outpatient investigation. B Intravenous fluids: administer IV fluid resuscitation in patients with hemodynamic instability and/or suspected ongoing bleeding, aiming for normalization of BP and HR before endoscopic evaluation/intervention. B Management of anticoagulant and antiplatelet therapy, general principles: As per ACG 2023 guidelines, resume anticoagulation after cessation of LGIB as the resumption of anticoagulation decreases the risks of post-bleeding thromboembolism and mortality. B As per BSG 2019 guidelines, consider administering LMWH at 48 hours after bleeding in patients with high thrombotic risk (such as prosthetic metal heart valve in the mitral position, AF with prosthetic heart valve or mitral stenosis, < 3 months after VTE). B As per ACG 2016 guidelines: Ensure a multidisciplinary approach (including hematology, cardiology, neurology, and gastroenterology) when deciding whether to discontinue medications or use reversal agents to balance the risk of ongoing bleeding with the risk of thromboembolic events in patients on anticoagulant agents. B Consider performing endoscopic hemostasis in patients with an INR of 1.5-2.5, before or concomitant with the administration of reversal agents. Consider administering reversal agents before endoscopy in patients with an INR > 2.5. C Management of anticoagulant and antiplatelet therapy, warfarin: As per ACG 2023 guidelines: https://web.pathway.md/diseases/recylSZ8CuaSh0o20 5/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway Consider reversing vitamin K antagonists in patients presenting with life-threatening LGIB and having an INR substantially exceeding the therapeutic range, although most patients with LGIB on vitamin K antagonists are unlikely to require reversal. C Prefer a 4-factor PCC over FFP due to the rapidity of INR reduction to prevent stroke in nonvalvular AF in patients on vitamin K antagonists requiring reversal. B As per CAG/ACG 2022 guidelines: Avoid administering FFP or vitamin K in patients on warfarin hospitalized or under observation with acute gastrointestinal bleeding. D Insufficient evidence to recommend for or against PCC administration in patients on warfarin hospitalized or under observation with acute gastrointestinal bleeding. I Consider administering PCC over FFP in patients on warfarin hospitalized or under observation with acute gastrointestinal bleeding. I As per BSG 2019 guidelines, discontinue warfarin therapy at presentation. B Show 2 more Management of anticoagulant and antiplatelet therapy, DOACs: As per ACG 2023 guidelines, consider reversing direct OACs in the small subset of patients on direct OACs presenting with life-threatening LGIB not responding to initial resuscitation and cessation of the anticoagulant alone. Administer targeted reversal agents (idarucizumab for dabigatran and andexanet alfa for apixaban and rivaroxaban), when available, if the direct OAC has been taken within the past 24 hours in patients requiring reversal. C As per CAG/ACG 2022 guidelines, avoid administering PCC in patients on direct OACs hospitalized or under observation with acute gastrointestinal bleeding. D Show 2 more As per BSG 2019 guidelines, discontinue direct OAC therapy at presentation. B Show 2 more Management of anticoagulant and antiplatelet therapy, antiplatelets: As per ACG 2023 guidelines, consider discontinuing aspirin for primary cardiovascular prevention after hospitalization for diverticular hemorrhage given the risks of recurrent diverticular hemorrhage. C Discontinue nonaspirin NSAIDs after hospitalization for diverticular hemorrhage. B Show 2 more As per CAG/ACG 2022 guidelines, avoid administering platelet transfusion in patients on antiplatelet agents hospitalized or under observation with acute gastrointestinal bleeding. D Show 2 more As per BSG 2019 guidelines, consider discontinuing aspirin permanently in patients taking it for primary prophylaxis of cardiovascular events. C Show 3 more Tranexamic acid: As per ACG 2023 guidelines, do not use antifibrinolytic agents, such as tranexamic acid, in patients with LGIB. D https://web.pathway.md/diseases/recylSZ8CuaSh0o20 6/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway As per BSH 2022 guidelines, do not use tranexamic acid in patients with acute gastrointestinal bleeding. D As per ESICM 2021 guidelines: Avoid using high-dose IV tranexamic acid in critically ill patients with gastrointestinal bleeding. D Insufficient evidence to support the use of low-dose IV or enteral tranexamic acid in critically ill patients with gastrointestinal bleeding. I Iron therapy: consider initiating iron therapy, after an appropriate negative evaluation, in clinically stable patients without recurrent bleeding, and follow clinically if iron deficiency is present. C 5. Therapeutic procedures Red blood cell transfusion: As per ACG 2023 guidelines, consider using a restrictive strategy of RBC transfusion (threshold for transfusion at a Hgb level of 7 g/dL) in hemodynamically stable patients with LGIB. C As per ESICM 2021 guidelines, consider setting a restrictive (7 g/dL) RBC transfusion threshold in patients with non-massive gastrointestinal bleeding. C As per BSG 2019 guidelines, set restrictive RBC thresholds (Hgb trigger 7 g/dL, and Hgb concentration target of 7-9 g/dL after transfusion) in clinically stable patients who may need RBC transfusion. Set a trigger of 8 g/dL and a target of 10 g/dL in patients with a history of CVD. B Platelet and plasma transfusion: Consider administering platelet transfusion to maintain a platelet count of 50 10 cells/L in patients with severe bleeding and in patients requiring endoscopic hemostasis. C Consider administering platelet and plasma transfusions in patients receiving massive RBC transfusions. C Endoscopic hemostasis (general principles): Perform endoscopic hemostasis in patients with any of the following high-risk endoscopic stigmata of bleeding: active bleeding (spurting and oozing) non-bleeding visible vessel adherent clot. B Show 2 more Endoscopic hemostasis, diverticular bleeding: As per ACG 2023 guidelines, use through-the-scope clips or perform endoscopic band ligation or coagulation for the treatment of diverticular stigmata of hemorrhage when detected. B https://web.pathway.md/diseases/recylSZ8CuaSh0o20 7/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway As per ASGE 2014 guidelines: Perform endoscopic injection of epinephrine combined with thermal coagulation or endoscopic clip placement as the preferred management in patients with diverticular bleeding. A Place an endoscopic clip or tattoo adjacent to a bleeding diverticulum if identified at lower gastrointestinal endoscopy for future localization in the event of recurrent bleeding. B Endoscopic hemostasis, angioectasia bleeding: As per ACG 2016 guidelines, perform non-contact thermal therapy with argon plasma coagulation for angioectasia bleeding. B As per ASGE 2014 guidelines, perform endoscopic argon plasma coagulation as the preferred management in patients with bleeding angioectasias. A Endoscopic hemostasis (post-polypectomy bleeding): perform mechanical (clips) or contact thermal endotherapy, with or without the combined use of dilute epinephrine injection, for post- polypectomy bleeding. B Angioembolization: As per BSG 2019 guidelines, perform catheter angiography with a view to embolization, where indicated, as soon as possible after a positive CT angiography to maximize the chances of success. Ensure that this is available within 60 minutes for hemodynamically unstable patients in centers with a 24/7 interventional radiology service. B As per ASGE 2017 guidelines, perform angiography for selective embolization in patients with hemodynamically unstable suspected small bowel bleeding, after appropriate hemodynamic resuscitation. B As per ACG 2016 guidelines, consider performing radiographic interventions in patients with high-risk clinical features and ongoing bleeding with a negative upper endoscopy not responding adequately to hemodynamic resuscitation efforts and are therefore unlikely to tolerate bowel preparation and urgent colonoscopy. B 6. Surgical interventions Indication for surgery: As per BSG 2019 guidelines, do not perform emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities, except under exceptional circumstances. D As per ACG 2016 guidelines, obtain surgical consultation in patients with high-risk clinical features and ongoing bleeding. B Show 2 more 7. Preventative measures https://web.pathway.md/diseases/recylSZ8CuaSh0o20 8/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway Secondary prevention: avoid using non-aspirin NSAIDs in patients with a history of acute LGIB, particularly if secondary to diverticulosis or angioectasia. D 8. Follow-up and surveillance Indications for specialist consultation: obtain surgical and radiologic consultation in patients with severe hematochezia unable to be stabilized for endoscopy or if endoscopic evaluation failed to reveal a bleeding source. B Management of recurrent bleeding: repear colonoscopy, with endoscopic hemostasis if indicated, in patients with evidence of recurrent bleeding. B 9. Quality improvement Hospital standards: ensure that all hospitals have a gastrointestinal bleeding lead and agreed pathways for the management of acute LGIB. E Show 2 more Clinical findings Symptoms Past medical history Abdominal pain Colorectal polyps Chest pain HHT Difficulty breathing IBD Fainting Iron deficiency anemia Hematochezia Liver cirrhosis Lightheadedness Malignancy Loss of consciousness Mesenteric ischemia Melena Portal hypertension Rectal bleeding Proctitis Medication history Past surgical history Anticoagulants Gastrointestinal surgery Antiplatelets Vital signs Social history Hypotension Alcohol consumption Signs of shock Tobacco use Tachycardia Vascular exam Abdominal exam Hypovolemia Peritoneal findings https://web.pathway.md/diseases/recylSZ8CuaSh0o20 9/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway Rectal exam Integument exam Anal fissures Pallor Hematological findings Imaging findings Anemia Contrast extravasation Intraluminal accumulation of radiotracer Endoscopic findings Angiodysplasia Likelihood Ratios Pertinent positives The following findings increase the probability of lower gastrointestinal bleeding in adults. 12 13 Finding LR+ Value Presence of evidence of recent or ongoing bleeding 78 Presence of intraluminal accumulation of radiotracer 18.6 Pertinent negatives The following findings decrease the probability of lower gastrointestinal bleeding in adults. 12 13 Finding LR- Value Absence of intraluminal accumulation of radiotracer 0.1 Absence of evidence of recent or ongoing bleeding 0.22 Studies 2020 HALT-IT In adult patients with significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding, tranexamic acid was not superior to placebo with respect to the rate of death due to bleeding within 5 days. HALT-IT Trial Collaborators. Lancet. 2020 Jun 20. 2018 SUP-ICU In adults admitted to the ICU for an acute condition who were at risk for gastrointestinal bleeding, pantoprazole was not superior to placebo with respect to death at 90 days. Krag M et al. N Engl J Med. 2018 Dec 6. https://web.pathway.md/diseases/recylSZ8CuaSh0o20 10/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway References 1. ASGE Standards of Practice Committee, Suryakanth R Gurudu, David H Bruining et al. The role of endoscopy in the management of suspected small-bowel bleeding. Gastrointest Endosc. 2017 Jan;85 1 22 31. Open 2. Neil Sengupta, Joseph D Feuerstein, Vipul Jairath et al. Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol. 2023 Feb 1;118 2 208 231. Open 3. ASGE Standards of Practice Committee, Shabana F Pasha, Amandeep Shergill et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc. 2014 Jun;79 6 875 85. Open 4. Neena S Abraham, Alan N Barkun, Bryan G Sauer et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol. 2022 Mar 17. Open 5. Lisa L Strate, Ian M Gralnek. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111 4 459 74. Open 6. Marco Pennazio, Emanuele Rondonotti, Edward J Despott et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy ESGE Guideline Update 2022. Endoscopy. 2023 Jan;55 1 58 95. Open 7. Oakland K, Chadwick G, East JE et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut. 2019 May;68 5 776 789. Open 8. Alexander P J Vlaar, Joanna C Dionne, Sanne de Bruin et al. Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2021 Dec;47 12 1368 1392. Open 9. Simon J Stanworth, Kerry Dowling, Nikki Curry et al. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol. 2022 Jun 10. Open 10. Gralnek IM, Neeman Z, Strate LL. Acute Lower Gastrointestinal Bleeding. N Engl J Med. 2017 Mar 16;376 11 1054 1063. Open 11. Almadi MA, Barkun AN. Patient Presentation, Risk Stratification, and Initial Management in Acute Lower Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am. 2018 Jul;28 3 363 377. Open 12. Kim BS, Li BT, Engel A et al. Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World J Gastrointest Pathophysiol. 2014 Nov 15;5 4 467 78. Open 13. Vernava AM rd, Moore BA, Longo WE et al. Lower gastrointestinal bleeding. Dis Colon Rectum. 1997 Jul;40 7 846 58. Open 14. Laing CJ, Tobias T, Rosenblum DI et al. Acute gastrointestinal bleeding: emerging role of multidetector CT angiography and review of current imaging techniques. Radiographics. 2007 Jul-Aug;27 4 1055 70. Open 15. Wu LM, Xu JR, Yin Y et al. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis. World J Gastroenterol. 2010 Aug 21;16 31 3957 63. Open https://web.pathway.md/diseases/recylSZ8CuaSh0o20 11/12 6/29/23, 5:55 AM Lower gastrointestinal bleeding Pathway 16. Halvorsen S, Storey RF, Rocca B et al. Management of antithrombotic therapy after bleeding in patients with coronary artery disease and/or atrial fibrillation: expert consensus paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J. 2017 May 14;38 19 1455 1462. Open 17. Kathryn Oakland, MD, Sandeepkumar Kothiwale et al. External Validation of the Oakland Score to Assess Safe Hospital Discharge Among Adult Patients With Acute Lower Gastrointestinal Bleeding in the US. JAMA Netw Open. 2020 Jul; 3 7 e209630. Open 18. Kathryn Oakland, Vipul Jairath, Raman Uberoi et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol. 2017 Sep;2 9 635 643. Open 19. Antonio Tarasconi, Gennaro Perrone, Justin Davies et al. Anorectal emergencies: WSES AAST guidelines. World J Emerg Surg. 2021 Sep 16;16 1 48. Open 20. ASGE Standards of Practice Committee, Mouen A Khashab, Krishnavel V Chithadi et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc. 2015 Jan;81 1 81 9. Open https://web.pathway.md/diseases/recylSZ8CuaSh0o20 12/12