Acute Lower Gastrointestinal Bleeding: Evaluation and Management

 

Am Fam Physician. 2020 Feb 15;101(4):206-212.

Author disclosure: No relevant financial affiliations.

Evaluation and management of acute lower gastrointestinal bleeding focus on etiologies originating distally to the ligament of Treitz. Diverticular disease is the most common source, accounting for 40% of cases. Hemorrhoids, angiodysplasia, infectious colitis, and inflammatory bowel disease are other common sources. Initial evaluation should focus on obtaining the patient’s history and performing a physical examination, including evaluation of hemodynamic status. Subsequent evaluation should be based on the suspected etiology. Most patients should undergo colonoscopy for diagnostic and therapeutic purposes once they are hemodynamically stable and have completed adequate bowel preparation. Early colonoscopy has not demonstrated improved patient-oriented outcomes. Hemodynamic stabilization using normal saline or balanced crystalloids improves mortality in critically ill patients. For persistently unstable patients or those who cannot tolerate bowel preparation, abdominal computed tomographic angiography should be considered for localization of a bleeding source. Technetium Tc 99m–labeled red blood cell scintigraphy should not be routinely used in the evaluation of lower gastrointestinal bleeding. Surgical intervention should be considered only for patients with uncontrolled severe bleeding or multiple ineffective nonsurgical treatment attempts. Percutaneous catheter embolization should be considered for patients who are poor surgical candidates. Treatment is based on the identified source of bleeding. (Am Fam Physician. 2020;101(4):206–212. Copyright © 2020 American Academy of Family Physicians.)

Acute lower gastrointestinal (GI) bleeding occurs distally to the ligament of Treitz. This article focuses on bleeding isolated to the colon and rectum. Lower GI bleeding has an incidence of 20 to 30 cases per 100,000 person years and accounts for 20% of GI bleeds.14 It requires admission to the hospital in 20 to 30 per 100,000 patients5 and has a mortality rate of 4%.1,6

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Patients with hemorrhoidal bleeding who are younger than 40 years and have no red flag symptoms (e.g., weight loss, fever, anemia, personal or family history of colon cancer, ineffective medical management) do not require endoscopy.15,17

C

Expert opinion and a consensus guideline in the absence of clinical trials

Nasogastric lavage should not be used to rule out a source of upper GI bleeding.7,24

B

Retrospective observational study showed that addition of nasogastric lavage to scoring systems does not confer additional benefit in the diagnosis of upper GI bleeding

Early colonoscopy (within 24 hours of presentation) is not preferred in hemodynamically unstable patients because it does not improve mortality, adverse events, rebleeding rates, or the need for surgery or blood transfusions.1,25,26

B

Two meta-analyses and a matched analysis showed no significantly improved patient-oriented outcomes with early vs. late colonoscopy

Nonaspirin nonsteroidal anti-inflammatory drugs should be avoided in patients with history of diverticular or angiodysplasia lower GI bleeding.2,13,14

C

Expert opinion, a consensus guideline, and a single cohort study


GI = gastrointestinal.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Patients with hemorrhoidal bleeding who are younger than 40 years and have no red flag symptoms (e.g., weight loss, fever, anemia, personal or family history of colon cancer, ineffective medical management) do not require endoscopy.15,17

C

Expert opinion and a consensus guideline in the absence of clinical trials

Nasogastric lavage should not be used to rule out a source of upper GI bleeding.7,24

B

Retrospective observational study showed that addition of nasogastric lavage to scoring systems does not confer additional benefit in the diagnosis of upper GI bleeding

Early colonoscopy (within 24 hours of presentation) is not preferred in hemodynamically unstable patients because it does not improve mortality, adverse events, rebleeding rates, or the need for surgery or blood transfusions.1,25,26

B

Two meta-analyses and a matched analysis showed no significantly improved patient-oriented outcomes with early vs. late colonoscopy

Nonaspirin nonsteroidal anti-inflammatory drugs should be avoided in patients with history of diverticular or angiodysplasia lower GI bleeding.2,13,14

C

Expert opinion, a consensus guideline, and a single cohort study


GI = gastrointestinal.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality pati

The Authors

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MATTHEW K. HAWKS, MD, is an assistant professor at the Uniformed Services University of the Health Sciences, Bethesda, Md....

JENNIFER E. SVARVERUD, DO, is a core faculty member of the Nellis Family Medicine Residency at the Mike O’Callaghan Military Medical Center at Nellis Air Force Base, Nev.

Address correspondence to Matthew K. Hawks, MD, 4301 Jones Bridge Rd., Bethesda, MD 20814 (email: matthewkhawks@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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