New European Society of Gastrointestinal Endoscopy Guideline on Acute Lower GI Bleeding

These are highlights of the European Society of Gastrointestinal Endoscopy’s new guideline on the diagnosis and management of acute lower GI bleeding:

• In cases of self-limited bleeding with no adverse clinical features, patients with an Oakland score of ≤8 can be discharged for outpatient investigation. 
• Patients who are hemodynamically stable and have no history of cardiovascular disease should undergo transfusion if the hemoglobin (Hb) is ≤7 g/dL, with a target of 7 to 9 g/dL after the transfusion.
• Hemodynamically stable patients with a history of cardiovascular disease should undergo transfusion if the Hb is ≤8 g/dL, with a target of ≥10 g/dL.
• Colonoscopy should be performed during the hospital stay, but there is no high-quality evidence that early colonoscopy is better.
• If a patient has hemodynamic instability, CT angiography is the first test to perform.
• Vitamin K and 4-factor prothrombin complex concentrate (PCC) should be administered to hemodynamically unstable patients or, if PCC is unavailable, fresh frozen plasma should be used.
• Direct oral anticoagulants should be temporarily withheld at presentation. 
• Low-dose aspirin does not have to be withheld, but if held, it should be resumed within 5 days if hemostasis is achieved and no further bleeding is evident. 
• Stopping dual antiplatelet therapy is not warranted before a cardiology consultation.
• Low-dose aspirin can be continued, and P2Y12 receptor antagonists can be continued or temporarily stopped, according to bleeding severity and ischemia risk. If a drug is still indicated, P2Y12 receptor antagonists should be restarted within 5 days.
• If CT angiography is negative in hemodynamically unstable patients, upper endoscopy should be considered.
• Surgery should be considered in hemodynamically unstable patients if endoscopic or radiologic treatment is unfeasible.
• In hemodynamically stable patients, consider clipping or band ligation for diverticular bleeding, argon plasma coagulation for angiodysplasia, and clips or thermal treatment for delayed postpolypectomy bleeding.