Massive lower GI bleed — resuscitation, Oakland and CTA-first pathway

Resuscitation. ABCDE. Two large-bore cannulae (14–16 G). Crossmatch 4 units / activate major haemorrhage if torrential. Balanced crystalloid boluses titrated to perfusion. Restrictive transfusion to Hb 70 g/L (80 g/L if ischaemic heart disease) — over-transfusion promotes rebleeding.^[1] Urinary catheter; serial lactate and Hb. Do not give PPI, terlipressin, octreotide or routine antibiotics (upper-GI drugs). Do not give routine TXA (HALT-IT no mortality benefit).^[6]

Exclude brisk UGIB. Haematochezia with shock is upper source until proven otherwise. NG aspirate if doubt; raised urea:creatinine supports digested blood; early OGD if upper pathway suspected.^[1]

Anticoagulation. Life-threatening apixaban bleed → andexanet if available, else PCC 25–50 units/kg. Hold further DOAC; plan early resumption after haemostasis.^[1]

Imaging. Unstable ongoing LGIB → CT angiography first, not colonoscopy (unprepped bowel + instability). CTA detects extravasation ~0.3–0.5 mL/min and triages to IR.^[1] Oakland scoring is for stable patients only — not this man.

Definitive haemostasis. Positive CTA → superselective mesenteric embolisation. If embolisation fails/recurs → surgery (segmental colectomy). If stabilises → colonoscopy within 24 h after prep for endoscopic therapy (epinephrine 1:10,000 + clip/APC). HDU/ICU disposition.^[1]