The British Society of Gastroenterology (BSG) has issued the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB).
Key recommendations include:
- Stratify LGIB as stable or unstable (shock index >1) and stable bleeds as major or minor.
- Patients with minor self-terminating bleed and no other indications can be discharged for urgent outpatient investigation.
- Admit patients with major bleed for colonoscopy.
- CT angiography (CTA) before endoscopy or radiology in patients with haemodynamic instability after initial resuscitation and/or suspected active bleeding.
- Immediate upper endoscopy for haemodynamically unstable LGIB if no source is identified by initial CTA.
- Catheter angiography as soon as possible after positive CTA.
- In general, emergency laparotomy should not be performed unless every effort has been made to localise bleeding with radiology and/or endoscopy.
- In stable patients (without a history of cardiovascular disease) requiring transfusion, a threshold of haemoglobin trigger of 70 g/L and Hb concentration target of 70-90 g/L after transfusion should be used.
- Interrupt warfarin at presentation. In unstable gastrointestinal haemorrhage, reverse anticoagulation with prothrombin complex concentrate and vitamin K.
- In patients with high thrombotic risk, consider low molecular weight heparin 48 hours after haemorrhage.
- Permanently discontinue aspirin for primary CVD prophylaxis.
- Do not routinely stop aspirin for secondary prevention.
- Do not routinely stop dual P2Y12 receptor antagonist and aspirin therapy in patients with coronary stents.
- In unstable haemorrhage, continue aspirin if P2Y12 antagonist is interrupted.
- Interrupting direct oral anticoagulant therapy at presentation. Considering treatment with idarucizumab or andexanet for life-threatening haemorrhage on direct oral anticoagulants.