EM · Lower gastrointestinal bleed
Lower gastrointestinal bleed
Also known as Lower GI haemorrhage · Acute lower GI bleeding · Haematochezia · Diverticular bleed · Angiodysplasia bleed · Massive lower GI bleed
The lower gastrointestinal bleed — the haemorrhage distal to the ligament of Treitz presenting with haematochezia, dominated by the diverticular bleed (the commonest cause), the inflammatory bowel disease, the colorectal cancer, the angiodysplasia and the haemorrhoids. Risk stratification with the Oakland score (a score of 8 or less predicting safe discharge). Localisation with the CT angiography for the unstable patient and the colonoscopy within 24 hours for the stable. Management with the ABCDE, the fluid resuscitation, the restrictive transfusion to a haemoglobin of 70 g/L, the endoscopic therapy (epinephrine injection and clipping), and the superselective mesenteric angiographic embolisation for the ongoing bleed — always excluding the upper source first. ACEM-primary, globally tagged.
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Red flags
- Haematochezia with haemodynamic compromise is an upper GI bleed with rapid transit until proven otherwise — nasogastric aspirate and early upper endoscopy if any doubt
- The unstable lower GI bleed gets the CT angiography first, not the colonoscopy — active bleeding and unprepped bowel defeat the endoscope
- The proton pump inhibitor, the terlipressin and the prophylactic antibiotic are upper GI bleed drugs with no role in the lower GI bleed — giving them is a Fellowship error
- Restrictive transfusion to a haemoglobin of 70 g/L — the over-transfusion disrupts clot and raises the rebleeding
- Never attribute a massive bleed to the haemorrhoids alone — the haemorrhoid coats the stool with blood, it does not produce the clot-filled lavatory bowl; miss the proximal cancer at your peril
Meet the patient
A 74-year-old man on apixaban for atrial fibrillation arrives with a large volume of clotted haematochezia and presyncope — systolic BP 84 palp, heart rate 128, Hb 88. The registrar reaches for the omeprazole, the terlipressin, and a bowel preparation for colonoscopy. Each is wrong.[1]
This is the massive lower GI bleed, and stability drives everything. The unstable patient gets CT angiography first, not colonoscopy; he gets restrictive transfusion to a haemoglobin of 70 g/L (80 with ischaemic heart disease); and he gets the apixaban reversed agent-specifically. The PPI, the terlipressin and the prophylactic antibiotic are upper-GI-bleed drugs with no role here — giving them is a Fellowship error. Hold that single fork and the whole station falls into place.[1]
References6ShowHide
- [1]Sengupta N, Feuerstein JD, Jairath V, et al. Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline Am J Gastroenterol, 2023.PMID 36735555
- [2]Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding Am J Gastroenterol, 2016.PMID 26925883
- [3]Oakland K, Jairath V, Uberoi R, et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study Lancet Gastroenterol Hepatol, 2017.PMID 28651935
- [4]Oakland K, Kothiwale S, Forehand T, et al. External Validation of the Oakland Score to Assess Safe Hospital Discharge Among Adult Patients With Acute Lower Gastrointestinal Bleeding in the US JAMA Netw Open, 2020.PMID 32633766
- [5]Yu Q, Funaki B, Ahmed O Twenty years of embolization for acute lower gastrointestinal bleeding: a meta-analysis of rebleeding and ischaemia rates Br J Radiol, 2024.PMID 38364312
- [6]HALT-IT Trial Collaborators Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial Lancet, 2020.PMID 32563378