LOWER GI BLEED:

-DDx: Diverticular bleeding, ischemic colitis , hemorrhoids, colorectal polyps/neoplasms , angioectasia, post-polypectomy bleeding, inflammatory bowel disease, infectious colitis, rectal ulcer, colorectal varices, radiation proctitis drug-induced colitis, and Dieulafoy’s lesion

-Associated sx: fevers, night sweats, weight loss, constipation, hard stools, straining, pain with defecation, syncope, abdominal pain,

- medicines (anticoagulants, aspirin, NSAIDs), illicit drugs

- recent surgery?

- cirrhotic with varices?

-Fam Hx GI cancers?

-On AC?

-Hx of prior radiation-radiation proctitis or colitis

-receptive anal intercourse?

-Previous GI bleeding: previous melena, BRBPR, hematemesis

-Prior EGD's: ***

-Prior Colonoscopies: ***

Oakland score <8 may be discharged for urgent outpatient investigation. https://www.mdcalc.com/calc/10042/oakland-score-safe-discharge-lower-gi-bleed

SHA2PE score <1 indicates hospital-based intervention is unlikely

PLAN:

-NPO @ MN *** for Colonoscopy ***Flex Sig the following day, maintain on clear liquid diet today

-2 large bore IV's

-trend CBC at least q12hr, or more frequently pending patient's clinical status

-optimize hemodynamically (BP, HR, respiratory status)

-optimize labs: Goal hemoglobin >7 (or >8 if active cardiac ischemia), goal SBP>100, goal platelets >50

-Active Type & Screen

--If overt hemodynamically significant bleeding, please order STAT CTA and consult IR if lower GI source

If concern for upper GI bleed

-IV PPI BID

-send H. Pylori

-avoid NSAIDs

Anticoagulation:

P2Y12's: High-risk procedures in patients on clopidogrel, prasugrel, and ticagrelor: Stop medications for 7 days (okay to continue aspirin), unless the patient underwent drug-eluting coronary stent placement less than 6 to 12 months ago or bare metal stent placement within the past month.

DoAcs: High-risk procedures in patients treated with DOACs who are at high risk of thromboembolism: Take the last dose 3 days before the endoscopy (except with dabigatran with a glomerular filtration rate of 30 to 50 ml/min, in which case the last dose should be taken 5 days before the procedure), and restart DOAC 2 to 3 days after the procedure.

Warfarin: High-risk procedures in patients at high risk for thromboembolism: Stop warfarin 5 days before the procedure, and bridge anticoagulant therapy before and after the procedure with low-molecular-weight heparin.

> For patients hospitalized with LGIB requiring a colonoscopy, we recommend performing a nonemergent inpatient colonoscopy because performing an urgent colonoscopy within 24 hours has not been shown to improve clinical outcomes such as rebleeding and mortality. (Strong recommendation, moderate-quality evidence)

>We recommend the performance of colonoscopy for most patients who are hospitalized with LGIB because of its value in detecting a source of bleeding (Strong recommendation, low-quality evidence).

>However, colonoscopy may not be needed in patients where bleeding has subsided, and the patient has had a high-quality colonoscopy within 12 months with an adequate bowel preparation showing diverticulosis with no colorectal neoplasia. (Conditional recommendation, very low-quality evidence)

>Patients with hemodynamic instability and/or suspected ongoing bleeding should receive intravenous fluid resuscitation with the goal of optimization of blood pressure and heart rate before endoscopic evaluation/intervention.

>Platelets should be administered in the setting of severe LGIB to maintain a platelet count of >30 × 109/L, and a higher threshold of >50 × 109/L can be considered if endoscopic procedures are required. There is no benefit to routine platelet transfusion for patients on antiplatelets.

>For patients with LGIB on cardiac aspirin for secondary prevention, aspirin should be continued during hospitalization if possible. Nonaspirin antiplatelets should be held initially for patients with severe hematochezia. However, for patients with recent cardiac stents within 1 year, a multidisciplinary approach should be used to determine the safety of temporarily holding antiplatelets.

References: