What is the optimal approach to managing acute lower gastrointestinal bleeding?
The ACG found limited evidence for most recommendations for managing acute lower gastrointestinal bleeding. They recommend risk stratification, nonurgent colonoscopy, and a restrictive policy on transfusions. For patients with severe bleeding, the ACG recommends CT angiography. (LOE = 5)
Overuse alert: This POEM aligns with the Canadian Society for Transfusion Medicine’s Choosing Wisely Canada recommendations. The Choosing Wisely Canada Why Give Two When One Will Do toolkit provides tools for reducing unnecessary red blood cell transfusions.
The American College of Gastroenterology (ACG) convened a panel that identified several questions related to the diagnosis, risk stratification, and management of acute lower gastrointestinal bleeding. Medical librarians conducted systematic literature searches for each question. The ACG did not describe the panel makeup or how they addressed financial or intellectual conflict of interest. Although the authors prioritized randomized trials, if none were available, they used observational studies. They used the GRADE system to assess the quality of the evidence for each of the statements. Many of their recommendations are conditional because of limited or low-quality evidence. While most of the recommendations pertain to gastroenterologists involved in the care of hospitalized patients, the panel made some recommendations about hospital follow-up and a few recommendations relevant to primary care clinicians. Please note that the strength of their recommendations does not necessarily flow from the quality of the evidence. These are a few that are relevant to primary care and emergency department clinicians.
- Do not administer antifibrinolytic agents, such as tranexamic acid.
- Colonoscopy during the hospitalization is your diagnostic friend, but there is no need to do it in the first 24 hours.
- In patients with diverticular hemorrhage, discontinue non-aspirin NSAIDs after hospitalization.
- Reevaluate the risks versus benefits of continuing non-aspirin antiplatelets, such as P2Y12 receptor antagonists, in a multidisciplinary setting after hospitalization for diverticular hemorrhage.
- Resume anticoagulation after cessation of lower gastrointestinal bleeding.
The guideline contains much more and includes useful tables and algorithms.
- Use a risk-stratification tool to identify low-risk patients who can be evaluated as outpatients.
- In hemodynamically stable patients, do not transfuse if the hemoglobin level is above 7 g/dL.
- Use reversal agents in patients taking vitamin K antagonists or direct-acting oral anticoagulants if the bleeding is life-threatening.
- An additional colonoscopy may not be needed for patients with a high-quality colonoscopy within 12 months and whose bleeding has clinically resolved.
- Computed tomography (CT) angiography is the initial diagnostic test in patients with ongoing hemodynamically significant hematochezia.
- Discontinue aspirin for primary cardiovascular prevention after hospitalization for diverticular hemorrhage. (Note: Aspirin for primary prevention is no longer recommended.) However, when used for secondary prevention, continue the aspirin.
Henry C. Barry, MD, MS
Michigan State University
East Lansing, MI