Endoscopy 2021; 53(08): 850-868
DOI: 10.1055/a-1496-8969
Guideline

Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Konstantinos Triantafyllou
 1   Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
,
Paraskevas Gkolfakis
 2   Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
,
Ian M. Gralnek
 3   Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
 4   Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
,
 5   Digestive Diseases and Renal Department, HCA Healthcare, London, UK
,
 6   Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese and Rho, Milan, Italy
,
Franco Radaelli
 7   Gastroenterology Department, Valduce Hospital, Como, Italy
,
 3   Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
,
Marine Camus Duboc
 8   Gastroenterology Department, Saint-Antoine Hospital, APHP Sorbonne University, Paris, France
,
Dimitrios Christodoulou
 9   Division of Gastroenterology, University Hospital & Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
,
Evgeny Fedorov
10   Department of Gastroenterology, Moscow University Hospital, Pirogov Russia National Research Medical University, Moscow, Russia
,
Richard J. Guy
11   Department of Emergency General Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
,
12   Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, Leipzig, Germany
,
Mostafa Ibrahim
13   Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
,
Ziv Neeman
 4   Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
,
Daniele Regge
14   Radiology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo
19   Department of Surgical Sciences, University of Turin, Turin, Italy
,
Enrique Rodriguez de Santiago
15   Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
,
Tony C. Tham
16   Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
,
Peter Thelin-Schmidt
17   Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
,
Jeanin E. van Hooft
18   Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
› Author Affiliations

Main Recommendations

1 ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.

Strong recommendation, low quality evidence.

2 ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.

Strong recommendation, moderate quality evidence.

3 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7–9 g/dL is desirable.
Strong recommendation, low quality evidence.

4 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.

Strong recommendation, low quality evidence.

5 ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.

Strong recommendation, low quality of evidence.

6 ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.

Strong recommendation, low quality evidence.

7 ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.

Strong recommendation, low quality evidence.

8 ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.

Strong recommendation, low quality evidence.

9 ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.

Strong recommendation, moderate quality evidence.

10 ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.

Strong recommendation, low quality evidence.

Appendix 1s, Tables 1s–17s



Publication History

Article published online:
01 June 2021

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