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Lower gastrointestinal bleeding (LGIB)

Dr Rajesh Varma

This is based upon the BSG’s UK national guideline on acute lower gastrointestinal bleeding (LGIB) published in 2019.

Background

  1. Around 10% of adults experience lower gastrointestinal bleeding (LGIB) each year.

  2. Major bleeding occurs in 1.3/1,000 and accounts for 3% of all emergency surgical admissions.

  3. In patient mortality is 3.4%.

  4. Lower GI bleeding accounts for 14% of all blood transfusions.

  5. In patients attending hospital, 25% have a low haemoglobin and 5% are shocked (SI>1).

  6. Early treatment reduces the need for blood transfusion.

Causes

  • Haemorrhoids
    Anal fissure
    Anorectal ulceration
    Inflammatory bowel disease (IBD)
    Coeliac disease
    Diverticular disease
    Ischaemic colitis
    Infective colitis
    Cancer (Lower GI)
    Angioectasia

  • Drugs (NSAIDs, warfarin or DOACs)

  • Upper GI bleeding presenting as LGIB

Investigations

Blood
FBC
CRP
ESR
Renal profile, liver function tests
Thyroid function test
Ferritin, B12, folate, Vitamin D
Coeliac serology (anti-TTG)
Ca125

Stool
stool culture
faecal calprotectin

Endoscopy
Colonoscopy and biopsy
Upper GI endoscopy is indicated if no source is identified by initial CT angiography

Management

ABC approach
Fluid resuscitation
Estimate blood loss and need for resuscitation (transfuse to achieve Hb 70-90 g/L or Hb 80-100 g/L if underlying cardiovascular disease)
No evidence to support routine use of anti-fibrinolytic drug tranexamic acid (awaiting results of HALT-IT trial)

Risk stratify as UNSTABLE or STABLE LGIB

UNSTABLE is defined as a shock index >1

Major bleeding causing shock (SI>1) should be managed by emergency hospital admission for resuscitation.
If haemodynamically unstable or shock index (heart rate/systolic BP) of >1 after initial resuscitation and/or active bleeding, recommend CT angiography
If there is extravasation of contrast, the source of bleeding can be identified and treated by embolisation or endoscopic therapy.

If STABLE bleed, classify as MAJOR OR MINOR LGIB using risk assessment tool such as the Oakland score

Major bleed should be admitted to hospital for colonoscopy on next available list
Patients who are not shocked with a MINOR self-terminating bleed (Oakland score ≤8 points) may be referred for urgent out patient investigation.

Shock Index and check Hb

SI is defined as heart rate (HR) divided by systolic blood pressure (SBP)
SI greater than or equal to 1.0 was associated with 40% mortality
SI has a normal range of 0.5 to 0.7 in healthy adults.

Seven variables comprising the Oakland score: used to distinguish major or minor stable bleeds

  1. Age

  2. Gender

  3. Previous LGIB admission

  4. DRE findings

  5. Heart rate

  6. Systolic blood pressure

  7. Haemoglobin (g/L)

Oakland score requires quantification of Hb, so it cannot be performed to reliability in primary care settings as same-day Hb is not available.

A patient with an Oakland score ≤8, is classified as a MINOR bleed and suitable for discharge from A&E and referral for outpatient colonoscopy.
6% of patients presenting with LGIB have an underlying bowel cancer, hence, endoscopy within 2 weeks is indicated in higher risk cases.

A patient with an Oakland score >8 is classified as a MAJOR bleed, and is likely to benefit from hospital admission and colonoscopy on the next available list.

Interventional radiology vs Colonoscopy/flexible sigmoidoscopy vs Laparotomy

Catheter angiography and embolisation should be performed as soon as possible after positive CT angiography
Mesenteric embolisation is recommended.
Embolisation may be undertaken using platinum coils, N-butyl cyanoacrylate and polyvinyl alcohol particles.
No patient should proceed to emergency laparotomy unless every effort has been made to localise bleeding by radiological and/or endoscopic modalities, except under exceptional circumstances.

Endoscopic options at colonoscopy include injection therapy (e.g. epinephrine), endoscopic clipping (through- and over-the-scope), thermal therapies (such as bipolar coagulation or argon plasma coagulation), and endoscopic band ligation, endoloops or haemostatic powders.

Suspected lower GI malignancy and 2-week wait referral

8% of people over 50 who report rectal bleeding will have a lower GI cancer.

Therefore, if age>50y + unexplained rectal bleeding, who do not need emergency admission, arrange urgent 2 week wait referral

Anticoagulant and Anti-platelet therapy and LGIB

  1. Warfarin Suspend warfarin, reverse (iv prothrombin complex concentrate and vitamin K), restart 7 days after haemorrhage; consider interim bridging measure of LMWH 48hr after LGIB if high thrombotic risk (ie. prosthetic metal heart valve in mitral position, atrial fibrillation with prosthetic heart valve or mitral stenosis, <3 months after venous thromboembolism)

  2. Aspirin for secondary prevention is NOT routinely stopped.

  3. Dual antiplatelet therapy DAPT with a P2Y12 inhibitor (such as clopidogrel) and aspirin is NOT routinely stopped in patients with coronary stents in situ. If severe LGIB, consider stopping P2Y12 inhibitor (clopidogrel) for 5 days but continuing with aspirin.

  4. DOAC Direct oral anticoagulant therapy Suspend, reverse if life-threatening (idarucizumab for dabigatran or andexanet for anti-factor Xa inhibitors), restart DOAC 7 days after haemorrhage.