Guideline Update - Management of Acute Lower Gastrointestinal Bleeding

Written by Andrea Eberly, MD, MS, FAAEM | Mar 30, 2023 4:46:03 PM

In February 2023, the American College of Gastroenterology (ACG) published new guidelines on acute lower gastrointestinal bleeding (LGIB), that replace their previous (2016) guidelines. What has changed?

Test your knowledge of the new guidelines with this case-based question and detailed explanation.

A 64-year-old man presenting to the emergency department with a 3 hour history of abrupt onset of painless hematochezia.

He is alert and oriented and his initial vital signs are HR 121 bpm (regular), BP 140/92 mm Hg, RR 16/min, room air pulse oximeter 95%.

Physical exam shows ongoing, significant hematochezia with blood clots. He denies nausea, vomiting, fever, chills, and any recent episodes of melena.

He states that he takes some kind of “blood thinning pill” because of his occasionally irregular heartbeat and its inherent stroke risk to him.

He does not take any other medications and is unaware of having any other medical problems.

He has no history of peptic ulcer or liver disease, and never had gastrointestinal bleeding before the current episode.

His hemoglobin level is 8.1 g/dL, his INR is 2.3, and his platelets are 250 x 109 L. He is given 1 L of normal saline.

According to the 2023 American College of Gastroenterology (ACG) guidelines on acute lower gastrointestinal bleeding (LGIB), what is a recommended next step in this patient’s management that is a departure from the ACG’s previous (2016) guidelines?

Answer Options:

Given the signs of early hemorrhagic shock in the context of being anticoagulated by an unknown agent, he should receive 4-factor prothrombin complex concentrate (PCC).
Given the signs of early hemorrhagic shock, his INR of 2.3, and hemoglobin of < 9.0 g/dL, he should receive 2 units of packed red blood cells and tranexamic acid.
Given his brisk bleeding, he should undergo CT angiography with referral to an interventional radiologist for arterial embolization or a gastroenterologist for endoscopic hemostasis if a bleeding source is found.
Given his brisk bleeding, he should undergo emergent colonoscopy with intent to perform endoscopic hemostasis if a bleeding source is found.

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