Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Abstract

Main Recommendations 1 ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7–9 g/dL is desirable.Strong recommendation, low quality evidence. 4 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5 ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9 ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10 ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.

Outcomes in high and low volume hospitals in patients with acute hematochezia in a cohort study

“…Although CT is more commonly performed in high-volume hospitals, the use of colonoscopy is the reverse of CT. Upper gastrointestinal bleeding should be suspected in cases of gastrointestinal bleeding with unstable vitals, even for patients presenting with acute hematochezia. CT was recommended as a first-line diagnostic modality www.nature.com/scientificreports/ for these patients [10][11][12][13][14] . Our finding that CT was performed more frequently in high-volume hospitals might explain the high proportion of patients with unstable vital signs, such as patients with upper gastrointestinal bleeding who presented with acute hematochezia.…”

“…A few recent studies have reported the therapeutic utility of ligation therapy for colonic diverticular bleeding 18,19 . Moreover, the guidelines for endoscopic clipping recommend that clips be placed onto the vessels by grasping directly, not in a zipper fashion, to ensure hemostatic effects [10][11][12][13][14] . However, the reason for the significant difference in the treatment methods between the groups was not clear in the present study.…”

“…Third, we performed path and mediation analyses on a colonoscopy-based strategy. However, because there are different paths, such as interventional radiology for the management of patients with acute hematochezia [10][11][12][13][14] , additional path and mediation analyses were required to evaluate the mediation effects between hospital characteristics and outcomes.…”

“…

Recently, path analysis and a generalized structural equation model (GSEM) have been used not only in causal pathways but also for the evaluation of complex network and mediation analysis 8,9 . As acute hematochezia has many possible causes and the diagnosis of ALGIB requires computed tomography (CT) and colonoscopy, management strategies remain complicated despite the currently available guidelines [10][11][12][13][14] . The introduction of path and mediation analyses may be required for the evaluation of these diagnostic and treatment modalities for patients with ALGIB.This propensity score-matched cohort study aimed to compare outcomes and management strategies for patients with acute hematochezia treated at the high-volume and low-volume hospitals for emergency medical services and perform path and mediation analyses that influence clinical outcomes using GSEM.

ResultsPatient characteristics.

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“…Recently, path analysis and a generalized structural equation model (GSEM) have been used not only in causal pathways but also for the evaluation of complex network and mediation analysis 8,9 . As acute hematochezia has many possible causes and the diagnosis of ALGIB requires computed tomography (CT) and colonoscopy, management strategies remain complicated despite the currently available guidelines [10][11][12][13][14] . The introduction of path and mediation analyses may be required for the evaluation of these diagnostic and treatment modalities for patients with ALGIB.…”