ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding

Abstract

This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal hemorrhage. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based upon clinical parameters should be performed to help distinguish patients at high and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper GI bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 hours of patient presentation after adequate colon preparation. 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. The endoscopic hemostasis modality used (mechanical, thermal, injection or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, CT angiography, 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. Strategies to prevent recurrent bleeding should be considered. NSAID use should be avoided in patients with a history of acute lower GI bleeding particularly if secondary to diverticulosis or angioectasia. In patients with established cardiovascular disease who require aspirin (secondary prophylaxis), aspirin should not be discontinued. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized and the source of bleeding should be carefully localized prior to resection.

Endoscopic and angiographic management of lower gastrointestinal bleeding: Review of the published literature

“…However, these recommendations have very low-quality evidence but strong or conditional recommendation levels. 18 Taking these recommendations into account radiological therapy is a less invasive complementary option for the diagnosis and therapy of LGIB, especially before a surgical procedure is chosen. Radiographic intervention could be considered especially in all patients with ongoing bleeding or when endoscopic therapy has failed 19 ( Figure 2).…”

Therapeutic water soluble contrast-thrombin enema use in bleeding colonic diverticula: A case report

“…If no upper gastrointestinal or anorectal source is found, then typically a colonoscopy is performed to find a lower gastrointestinal source. Mesenteric angiography in addition to nuclear scanning can also be undertaken in place of or as adjuncts to colonoscopy, depending on the clinical scenario [6,7].…”

Colonic Bleeding Due to Histoplasma and Mycobacterium Coinfection in Renal Transplant Patient

“…LGB (lower gastrointestinal bleeding), currently defined as bleeding originating distal to the ileocecal valve, is a frequently self-limited condition, but it can be severe and require specific therapeutic intervention in up to 15-20% of times [1]. Diverticulosis is the leading cause of LGB, mainly among the elderly, followed by vasculopathies and then by inflammatory causes [2].…”

“…Diverticulosis is the leading cause of LGB, mainly among the elderly, followed by vasculopathies and then by inflammatory causes [2]. Infections are rarely related to clinically significant bleeding (less than 5%), being more relevant among immunocompromised patients [1]. Histoplasmosis is a rare infectious condition that usually affects immunocompromised patients, mostly with advanced HIV infection, and secondly transplants patients.…”