Authors' results and conclusions: ▪ Evidence-based practice guidelines from major specialty societies recommend use of a risk appraisal tool such as the Oakland score to distinguish between minor and major bleeding of the lower gastrointestinal tract: patients with minor bleeding may be managed on an outpatient basis, while patients with major bleeding should be admitted to the hospital. ▪ CT angiography is recommended as the first procedure to localize the source of bleeding in unstable patients. CT is less sensitive in patients with minor bleeding and patients whose bleeding has subsided. ▪ Colonoscopy is recommended for patients who are stable. Earlier guidelines recommended colonoscopy within 24 hours of admission, but urgent colonoscopy has not been shown to improve outcomes in stable patients. Some guidelines recommend upper GI endoscopy to rule out an upper GI source of bleeding before proceeding to colonoscopy. ▪ Many of the guidelines give detailed recommendations and suggestions for use of endoscopic treatment modalities, including clipping, epinephrine injection, and argon plasma coagulation; in patients with different types of lower GI bleeding. See Table 7 for summaries of those recommendations. Surgery should be considered only after other options have failed. ▪ There is no consensus on treatment for patients with recurrent lower GI bleeding. ▪ If initial examinations fail to detect an upper GI or lower GI source in patients presenting with GI bleeding, the bleeding is categorized as obscure. Evidence on “second look” endoscopy in these patients is weak and guidance on it is inconsistent. Once other sources of obscure bleeding are ruled out, and the bleeding source is suspected to be in the small intestine, there is broad but not total agreement that video capsule endoscopy (VCE) should be performed. ▪ Guidelines consistently recommend restrictive transfusion thresholds for patients with acute lower GI bleeding. ▪ See the evidence tables in this report for guidance on withholding and resuming anticoagulant drugs in patients with acute lower GI bleeding. ▪ Many guidelines include suggested pathways for managing patients with acute lower GI bleeding, but none of these pathways have been validated in outcomes-based clinical trials.

Authors' recommendations: ▪ Evidence-based practice guidelines from major specialty societies recommend use of a risk appraisal tool such as the Oakland score to distinguish between minor and major bleeding of the lower gastrointestinal tract: patients with minor bleeding may be managed on an outpatient basis, while patients with major bleeding should be admitted to the hospital. ▪ CT angiography is recommended as the first procedure to localize the source of bleeding in unstable patients. CT is less sensitive in patients with minor bleeding and patients whose bleeding has subsided. ▪ Colonoscopy is recommended for patients who are stable. Earlier guidelines recommended colonoscopy within 24 hours of admission, but urgent colonoscopy has not been shown to improve outcomes in stable patients. Some guidelines recommend upper GI endoscopy to rule out an upper GI source of bleeding before proceeding to colonoscopy. ▪ Many of the guidelines give detailed recommendations and suggestions for use of endoscopic treatment modalities, including clipping, epinephrine injection, and argon plasma coagulation; in patients with different types of lower GI bleeding. See Table 7 for summaries of those recommendations. Surgery should be considered only after other options have failed. ▪ There is no consensus on treatment for patients with recurrent lower GI bleeding. ▪ If initial examinations fail to detect an upper GI or lower GI source in patients presenting with GI bleeding, the bleeding is categorized as obscure. Evidence on “second look” endoscopy in these patients is weak and guidance on it is inconsistent. Once other sources of obscure bleeding are ruled out, and the bleeding source is suspected to be in the small intestine, there is broad but not total agreement that video capsule endoscopy (VCE) should be performed. ▪ Guidelines consistently recommend restrictive transfusion thresholds for patients with acute lower GI bleeding. ▪ See the evidence tables in this report for guidance on withholding and resuming anticoagulant drugs in patients with acute lower GI bleeding. ▪ Many guidelines include suggested pathways for managing patients with acute lower GI bleeding, but none of these pathways have been validated in outcomes-based clinical trials.

Project Status: Completed

Year Published: 2023

URL for published report: https://www.med.upenn.edu/CEP/external-request-form.html

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Penn Medicine Center for Evidence-based Practice

Contact Address: Penn Medicine Center for Evidence-based Practice, University of Pennsylvania Health System, 3600 Civic Center Blvd, 3rd Floor West, Philadelphia PA 19104

Contact Name: Nikhil Mull

Contact Email: cep@pennmedicine.upenn.edu

Copyright: Center for Evidence-based Practice (CEP)