Evidence-based, cost-effective management of lower gastrointestinal bleeding. An algorithm of the journal of trauma and acute care surgery emergency general surgery algorithms work group

This algorithm was developed by the Journal of Trauma and Acute Care Surgery Emergency General Surgery algorithms working group to provide an evidence-based, practical approach to the initial evaluation and management of lower gastrointestinal (LGI) bleeding in adults presenting in the emergency setting.1 The algorithm (Fig. 1) is intended to serve as a bedside reference for clinicians. It is annotated with letters that link to the corresponding text, which provides the rationale and references to support these recommendations. The algorithm is not a substitute for the clinical judgment and experience of bedside clinicians and should not be considered the “standard of care.” We encourage institutions to use these recommendations to formulate local clinical protocols, recognizing that patient- and institutional-specific factors may necessitate deviations from this algorithm.Figure 1: LGI bleeding algorithm landscape.The reported incidence of LGI bleeding is 33 to 87/100,000 and accounts for 3% of emergency surgical referrals.1–4 The population of patients with LGI bleeding tends to be older with increased number of comorbidities than patients with upper gastrointestinal hemorrhage. While patients with LGI bleeding necessitate emergency surgical consultations, the optimal management of patients who present with hemodynamic instability requires a multimodality team comprised of acute care surgeons, gastroenterologists, and interventional radiologists.5–8 While the textbook definition of LGI bleeding is any bleeding distal to the Ligament of Treitz, the algorithm predominantly describes the approach to patients with LGI bleeding occurring between the ileocecal valve and the anal verge (colon, rectum, and anus). Small bowel hemorrhage is discussed in a separate section later in this manuscript. The most common etiology of LGI is diverticular disease, which accounts for up to 25% to 50% of cases.9 This is followed by anal and rectal pathology (hemorrhoids, fissures, and rectal ulcers), colitis, arteriovenous malformations, cancer, and polyps. Of note, in upwards of one quarter of patients, the source of their LGI bleed is never definitively found. The most common presentation of LGI bleeding is hematochezia or red blood per rectum.6–9 Compared to other forms of gastrointestinal bleeding; patients often seek medical attention urgently. One reason is that patients often present after a bowel movement, and the mixture of even a small quantity of blood with the water in the commode can be quite alarming, making the volume of hemorrhage appear quite large. LGI bleeding, even if severe, is self-limited in ≥80% of patients allowing time for a workup to be undertaken.6–8 LGI bleeding generally occurs in an older population (>70 y) with concomitant comorbidities, frailties, and in the presence of anticoagulation.10,11 While the overall mortality from LGI bleeding is low, ranging between 2% and 4%, the incidence is higher in older patients or those with comorbidities. Death is more commonly associated with the complications of bleeding rather than hemorrhage itself.12 Assessment As with any patient who is bleeding, assessment of the degree of hemorrhage is paramount. Vital signs, shock index, lactate, and base deficit remain crucial for assessing the presence and depth of hypoperfusion.13 It should also be recognized that in the older population, biochemical markers of shock such as lactate and base deficit may be less apparent than in a younger cohort.14 Blood should also be sent for coagulation studies and, if available, viscoelastic testing. As the population of patients with LGI bleeding often has significant cardiovascular disease, eliciting a medication history, especially anticoagulants, are critical. The use of anticoagulants such as warfarin, direct oral anticoagulants, or dual platelet therapy is associated with an increased risk of all GI bleeding.15,16 The decision-making regarding the management of anticoagulation in these patients is complicated and balances the risk of bleeding against the underlying indication for anticoagulation. These considerations will be discussed later in this manuscript. In addition to the standard physical examination, careful attention should be given to inspection and examination of the anus and distal rectum for the presence of hemorrhoids or other ano-rectal pathologies. Unless overt bleeding can be seen, current data does not support the performance of sigmoidoscopy in the unprepared colon.6–8 Hemodynamically Stable Patients The optimal way to categorize patients with LGI bleeding is to separate those who are hypotensive, require transfusion, or have signs of hypoperfusion from patients without signs of shock or significant blood loss. In the latter group, the decision to admit and evaluate or discharge the patient from the ED is significant. The most used and studied risk-adjusted tool is the Oakland Score (Table 1). This score was originally developed in 2,336 patients from 143 hospitals in the United Kingdom.17 The model was designed to identify predictors of safe discharge based on the minimal risk of rebleeding, blood transfusion, therapeutic intervention, 28-day readmission, or death. A score of ≤8 had a 95% chance of predicting a safe discharge. This score was further studied and validated in 38,067 patients across 140 hospitals in the United States and has been generally accepted as a standard for recommending discharge of patients with LGI bleeding from the ED with plans for further investigation as an outpatient.18,19 TABLE 1 - Oakland Score Variable Value Age group (y) ≤39 0 40–69 1 ≥70 2 Sex Female 0 Male 1 Previous hospitalization for LGI bleeding No 0 Yes 1 Initial heart rate (beats/min) ≤69 0 70–89 1 90–109 2 ≥110 3 Initial systolic blood pressure (mm Hg) 50–89 5 90–110 4 120–129 3 130–159 2 ≥160 0 Initial hemoglobin (g/dL) 3.6–6.9 22 7.0–8.9 17 9.0–10.9 13 11.0–12.9 8 13.0–15.9 4 ≥16.0 0 Total score is the sum of the six component values. An Oakland score ≤8 predicted safe hospital discharge, which was defined as the absence of all of the following: rebleeding, defined as additional blood transfusions requirements or a further decrease in hematocrit of 20% or more after 24 hours of clinical stability, red blood cell transfusion, therapeutic intervention to control bleeding, defined as endoscopic, radiologic, or surgical hemostasis, in-hospital death, and readmission with further LGI bleeding within 28 days. These patients are considered candidates for discharge from the ED. The ACG Guideline also recommends the use of another risk stratification tool, the SHA2PE score (Table 2), which predicts low risk of hospital-based intervention.20 It should be recognized that no prospective multicenter studies have validated the use of either the Oakland or SHA2PE scores in the ED. While these scores can help guide admission decisions, clinical judgment regarding a specific patient’s frailty, comorbidities, and distance from a health care facility able to care for them might influence the decision to pursue a workup during that index admission. TABLE 2 - SHA2PE Score for Prediction of Hospital-based Interventions Variable Score Systolic blood pressure