This guideline has been developed to aid in the management of adults presenting with an acute lower gastrointestinal bleed (LGIB). This guideline refers to patients who present with bright or dark red blood per rectum, clots per rectum or blood mixed in with the stool. The guideline is specifically for hospital care practitioners and provides advice about the involvement of the acute medical team, gastroenterology consultant, interventional radiologist and emergency surgical team where appropriate.

Nominated GI bleed Lead: Dr Susannah Woodrow

7-day access is available to on-site colonoscopy with the facilities to carry out endoscopic interventions at FHFT. This is supported by the ward gastroenterology consultants in hours, and by the GI bleed consultant out of hours. This is also supported by the 24/7 interventional radiology service at FHFT together with on-site access to abdominal surgery and access to HDU/ITU.

All patients presenting with LGIB should have a formal assessment of the risks the LGIB poses to the patient. LGIB should be stratified as unstable or stable (unstable defined as

a shock index >1). Stable bleeds should then be categorised as major or minor using clinical judgement. The Oakland score has been removed from the risk assessment for Lower GI bleeding.

• Patients presenting with a minor self-terminating bleed with no other indications for admission to hospital, can be discharged with urgent outpatient investigations.

• Colonoscopy within 2 weeks as per NICE guidelines especially if high suspicion of malignancy (6% of patients presenting with LGIB have an underlying bowel cancer) ⁽²⁾.

Bleeding per rectum requires urgent anal inspection.

For patients presenting with features of a LGIB, they firstly need to be classified as unstable or stable (unstable defined as a shock index of > 1). Shock index can be calculated by dividing the heart rate by the systolic blood pressure. Stable patients should then be further categorised into major and minor bleeds. For patients on Beta Blockers the shock index should be treated with caution.

Minor Stable Lower GI bleeding – Discharge with OP investigations

Low volume blood loss

Stable vital signs

Minimal anaemia

Self-limiting nature

Absence of severe co-morbid conditions

Major Stable Lower GI bleeding – Admit for LGI endoscopy on next available list

Significant blood loss

Haemodynamic stability

Moderate drop in haemoglobin

No severe symptoms or complications

Figure 1: Management algorithm for patients presenting with acute lower GI bleeding.

The resuscitation and initial management are the responsibility of A&E staff and subsequent team to whom the patient is referred. After initial resuscitation and if the patient remains stable, the following steps should be taken according to the time of day:

• Admit the patient (FPH – medical team, WPH – surgical team)

• The patient should be reviewed by the registrar of the admitting team.

• At FPH the Gastroenterology Ward Consultant can be contacted for advice.

• Admitting team to assess the patient as unstable or stable. Please see Figure 1.

• For the unstable patient the admitting team to liaise with IR urgently

• For stable patients, raise the appropriate endoscopy request on EPIC

• The endoscopy staff will then liaise with the endoscopist for the day. Depending on the clinical information, the patient will be sent for, or the consultant may contact the junior doctor for more details.

• The patient should be admitted (FPH – medical team, WPH – surgical team)

• The patient should be reviewed by the registrar of the admitting team.

• Admitting team to assess the patient as unstable or stable. Please see figure 1.

• For the unstable patient the admitting team to liaise with IR urgently via switchboard

• For stable patients, raise the appropriate endoscopy request on EPIC to be scoped on the next available list.

Anal conditions that can be managed by A&E

• Patients with anal conditions that can be managed by Accident & Emergency will arrange follow up with the colorectal team.

FPH offers regional interventional radiology services for intra-hospital transfers and regional hospital transfers. These patients are admitted under the surgeons, for if in the eventuality that IR fails then the patient would require surgery. If IR does not identify a bleed the patient is transferred back to the referring hospital the next day. If the patient needs a prolonged stay for other medical reasons, then the Gastroenterologists would take over the patient’s care at the earliest opportunity.

• Patients presenting with a minor self-terminating bleed with no other indications for admission to hospital, can be discharged with urgent outpatient investigations.

• Colonoscopy within 2 weeks as per NICE guidelines especially if high suspicion of malignancy (6% of patients presenting with LGIB have an underlying bowel cancer) ⁽²⁾.

1. ABCDE approach

2. Full history (where appropriate), observations and examination including a digital rectal exam (DRE)

3. Calculate the shock index to determine if the bleed is stable or unstable

4. Urgent bloods including VBG, FBC, U&Es, CRP, LFTs and clotting

5. Crossmatch 4 units of blood urgently if massive/unstable bleed; if not then send off an urgent group and save

6. IV access with 2 large bore cannulae (central venous catheterisation as this will only delay the resuscitation unless patient has heart failure, renal failure or difficult to manage fluid balance)

7. Volume replacement with crystalloids

8. Insert a urinary catheter and aim for a urine output of > 30ml/hour

9. High risk patients with a high Oakland score +/- Glasgow Blatchford score, or those who look clinically unwell consider referral to critical care and admission to MADU/HDU/ITU environment

Lower GI endoscopy has been recommended as the preferred initial investigation in patients classified as a having major or minor bleed as it has the potential for diagnosis, application of different therapeutic modalities and the ability to mark areas of pathology for potential surgical resection via tattoo injection. The patient should be listed on the next available lower GI endoscopy slot. Lower GI endoscopy can be performed sometime during their hospital stay because there is no high-quality evidence that early Lower GI endoscopy influences patient outcomes ⁽³⁾.

In patients presenting with a major bleed and are haemodynamically unstable; or have a shock index > 1 following initial resuscitation, CT angiography (CTA) should be the preferred initial evaluative technique as this provides the fastest and least invasive method of localising the site of blood loss before planning any further endoscopic or radiological interventions. Please liaise with interventional radiology urgently with these patients.

• Bleeding per rectum can also represent an upper GI bleed, therefore it is vital to speak to the gastroenterology consultant/registrar as to the appropriateness of an urgent OGD prior to a CTA if the patient is stable enough. If the patient is UNSTABLE, then CTA remains the initial investigation of choice.

• If no source is found on CTA, then UGI endoscopy should be performed immediately afterwards

• If CTA is positive, catheter angiography with a view to embolization should be performed as soon as possible, to maximise chances of success.

• If the CTA has been performed in only the portal-venous phase, it may be beneficial to do additional imaging in the arterial phase in the event of further bleeding

• CTA can also be beneficial for patients undergoing preoperative planning before embolization, surgery or interventional radiology

Bright red bleeding per rectum requires urgent anal inspection. If CTA does not reveal any obvious sources of bleeding, then these patients should have lower GI endoscopy to allow visualisation of the whole lower GI tract. Patients should receive adequate bowel preparation to enable sufficient visualisation of the mucosa. The bowel preparation regimen should be discussed with the Gastroenterology team.

Repeat CTA is of no benefit unless bleeding becomes more brisk. Video capsule endoscopy (VCE) is a non-invasive investigation allowing examination of the entire small bowel looking for GI bleeding in patients with negative upper and lower GI endoscopies. This technique has a higher diagnostic yield than of small bowel radiography, catheter angiography and push enteroscopy. The yield is high if performed within 48 hours of the bleeding episode.

Red cell Transfusion

Single unit transfusions are now recommended in patients who do not have active bleeding.

NICE recommends using restrictive red blood cell transfusion thresholds for patients who need red blood cell transfusions and who do not

• have major haemorrhage or

• have acute coronary syndrome or

• need regular blood transfusions for chronic anaemia

Trigger Haemoglobin (Hb) values for transfusion will vary depending on clinical assessment of ongoing bleeding, cardiovascular status, and co-morbidities.

• Haemodynamically stable patients with no evidence of ongoing bleeding and no cardiovascular disease have no need for transfusion unless Hb <70 g/l. Target post transfusion Hb 70-90 g/l ⁽⁵⁾.

• Check iron status and replace if deficient. Replace using IV iron rather than RBC if not actively bleeding and no cardiovascular compromise

• Haemodynamically stable patients with no evidence of ongoing bleeding but significant cardiovascular co-morbidity, transfusion trigger Hb <80 g/l. Target post transfusion Hb 10 g/l ⁽⁵⁾

• In major haemorrhage please follow trust Massive Haemorrhage Management protocol/Blood transfusion policy for adults with related guidelines on intranet.

• Platelet transfusion should be considered in haemodynamically unstable patients who are actively bleeding (WHO grade 2 with a platelet count less than 50 x10⁹/l ⁽³⁾.

• Use higher platelet thresholds (up to a maximum of 100×10⁹ per litre) for patients with thrombocytopenia and/or severe bleeding (WHO grades 3 and 4) ⁽³⁾.

• Consider prophylactic platelet transfusions to raise the platelet count above 50×10⁹ per litre in patients who are having invasive procedures or surgery.

• Do not offer prophylactic platelet transfusions unless discussed with the on-call Haematologist if known chronic bone marrow failure, autoimmune thrombocytopaenia, heparin-induced thrombocytopaenia, thrombotic thrombocytopaenic purpura

• Do not routinely transfuse more than one pool of platelets. Reassess after each pool transfused.

• Prothrombin Complex Concentrate (PCC):

  • patients taking a vitamin K antagonist e.g. warfarin (VKA) or a direct factor Xa inhibitor, e.g., rivaroxaban, apixaban, edoxaban, will need discussion with the on-call haematologist.

• Fresh Frozen Plasma (FFP): If a patient has a Prothrombin time ratio or Activated partial thromboplastin time ratio above 1.5) and are not taking any anticoagulants, i.e., VKA DOAC, with clinically significant bleeding then consider consider Fresh Frozen Plasma transfusion (Adult dose 15mls/kg)

• Consider Cryoprecipitate (Adult dose: 2 pools) if fibrinogen <1.5g/L in an unstable actively bleeding patient.

• Consider prophylactic Cryoprecipitate transfusions for patients with a fibrinogen level below 1.0 g/litre who are having invasive procedures or surgery with a risk of clinically significant bleeding.

Any patient whose anti-platelet or anticoagulant has been withheld should have a clear plan for resumption.

For all patients presenting with an acute LGIB and taking anticoagulation, we suggest the following advice:

• Warfarin therapy should be withheld at presentation in patients presenting with acute LGIB. If the patient is haemodynamically unstable/massive bleeding then it is recommended that anticoagulation is reversed with prothrombin complex concentrate and vitamin K.

  • For patients with a low thrombotic risk, warfarin should be restarted 7 days after presentation.

  • For patients with a high thrombotic risk (i.e. patients with a prosthetic metal mitral valve, AF with a prosthetic heart valve or mitral stenosis, thrombosis < 3months prior) a LMWH should be considered 48 hours after the initial presentation of bleeding if the INR is normal.

• In patients receiving unfractionated heparin, it is usually sufficient to discontinue the medication due to its short half-life, but in severe bleeds its effects can be reversed with protamine sulphate. Protamine sulphate is less effective in reversing LMWH as the half-life is longer (24 hours).

• DOAC therapy should be withheld in patients presenting with an acute LGIB.

  • Discuss with the consultant haematologist if the patient is presenting with a massive LGIB or haemodynamically unstable. Consider the use of idarucizumab (antidote for dabigatran) or andexanet (antidote for anti-factor Xa inhibitors) after discussion with haematology.

Consider restarting the DOAC within 7 days of the acute presentation if the patient is clinically stable

• In patients receiving aspirin monotherapy for primary prevention, it may be withheld on presentation with LGIB with little increase in the risk of thrombosis. Permanent discontinuation should be considered.

• Aspirin for secondary prevention should be continued. If it is stopped it should be restarted as soon as haemostasis is achieved. The risk of thrombosis is higher in this group of patients.

• P2Y12 inhibitors such as clopidogrel, ticlopidine, ticagrelor, prasugrel, and cangrelor should be held until haemostasis has been achieved.

• Patients on DAPT, experiencing a recent ischaemic event OR that have stents in situ should be discussed with the specialist responsible for this aspect of their care. E.g. if a patient has coronary artery stents, a decision regarding withholding antiplatelet therapy should be undertaken after discussion with a cardiologist.

It would be preferable for these patients to continue treatment due to the high risk of stent thrombosis.

• In the event of massive bleeding following DAPT, it is advisable to continue aspirin and stop clopidogrel. clopidogrel should then be reinstated within 5 days, once haemodynamically stable. Again, discussion is required with the cardiology team.

• Ideally P2Y12 inhibitors should be continued for 12 months after deployment of drug-eluting coronary artery stents or 1 month for bare metal stents. In the event of severe haemorrhage, it may be necessary to temporarily discontinue the P2Y12 inhibitor, but aspirin should be continued, with the aim to restart the P2Y12 inhibitor within 5 days.

The recent HALT-IT trial concluded there is no significant benefit for the use of tranexamic acid in the management of upper GI bleeds. Only very little data is available for its use in LGIB therefore we do not routinely advise it in the acute setting.

1. Oakland, K. et al. (2019) ‘Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology’, Gut, 68, pp. 776-789. Available at: https://gut.bmj.com/content/68/5/776.

2. National Institute for Health and Care Excellence (NICE) (2021) Suspected cancer: recognition and referral. NG12. Available at: https://www.nice.org.uk/guidance/ng12.

3. Triantafyllou K et al (2021) Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, Endoscopy 2021; 53(08): 850-868. Available at: Thieme E-Journals - Endoscopy / Abstract (thieme-connect.de)

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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