Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

Abstract

Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.

Outcomes and performance of risk scores in acute lower gastrointestinal bleeding

“…According to the American College of Gastroenterology guideline, 11 endoscopy within 24 h after the first presentation is recommended in high‐risk patients or patients with ongoing bleeding to improve diagnostic and therapeutic yields. Conversely, the latest guideline does not mention the appropriate timing of colonoscopy, but recommends to skip colonoscopy in selected patients if bleeding has subsided and the patient had high‐quality colonoscopy within the previous 12 months 17 . Nevertheless, the majority of our cohort underwent colonoscopy within 72 h, and most of them could be managed conservatively as hemostatic interventions were required only in 20% of cases.…”

“…Moreover, the most recent randomized multicenter trial from Japan does not show any benefit of urgent colonoscopy in acute LGIB 16 . Conversely, the latest guideline from the American College of Gastroenterology does not mention on the appropriate timing of colonoscopy, but also recommends to skip colonoscopy in selected patients if bleeding has subsided and the patient had high‐quality colonoscopy done in the last 12 months 17 …”

“…16 Conversely, the latest guideline from the American College of Gastroenterology does not mention on the appropriate timing of colonoscopy, but also recommends to skip colonoscopy in selected patients if bleeding has subsided and the patient had high-quality colonoscopy done in the last 12 months. 17 The objective of this study was to evaluate the characteristics of patients presenting acute LGIB and the therapeutic outcomes in a tertiary care center environment. Moreover, predictors of poor outcomes and the performance of risk stratification systems were also determined.…”

Diagnosis and management of acute lower gastrointestinal bleeding

“…The most common clinical presentation of acute LGIB is hematochezia (fresh blood/maroon colored stools passed per rectum) [4] and/or rarely melena (black tarry stools) [1 ▪▪ ,2,3]. LGIB presents most commonly in the elderly on a background of significant comorbid illnesses, and often in patients being treated with antiplatelet or anticoagulant medications [4,6,7].…”

“…Lower gastrointestinal bleeding (LGIB) is defined as bleeding originating from a colonic or rectal source distal to the ileocecal valve [1 ▪▪ ,2–4]. As reported by the United States (US) Centers for Disease Control, LGIB is among the most common gastroenterological causes for emergency department visits and hospital admissions, constituting approximately 30% of all GIB referrals, thereby rendering it a significant healthcare and economic burden [5 ▪ ].…”