Saturday, June 15, 2019

Clinical Practice Guidelines 2019 Acute lower gastrointestinal bleeding: 10 Key Takeaways

This year, the British Society of Gastroenterology released clinical practice guidelines on the diagnosis and management of acute lower gastrointestinal bleeding published online April 8, 2019 in the BMJ. 

Here are 10 key takeaways from the guidelines.

1.     Patients who present with low GI bleeding should be first categorized as unstable (shock index >1) or stable. The Oakland score can be used to categorize stable bleeds as minor or major. Patients with minor self-terminating bleed (Oakland score ≤8) can be discharged for urgent outpatient investigation, if there are no indications for hospitalization. But patients with major bleed should be hospitalized for colonoscopy on the next available list.
2.     Before planning endoscopic or radiological therapy, localize the site of bleeding quickly and least invasively via CT angiography in hemodynamically unstable patients or those who have shock index >1 after initial resuscitation and/or in whom active bleeding is suspected.
3.     If not source of bleeding can be identified on initial CT angiography in hemodynamically unstable patients, an upper GI endoscopy should be performed immediately. Gastroscopy may be the first investigation when patient stabilizes after initial resuscitation.
4.     If a source of bleeding is found on CT angiography, a catheter angiography with a view to embolization should be done at the earliest. Centers with a 24/7 interventional radiology service should be capable of performing catheter angiography for hemodynamically unstable patients within 60 minutes of admission
5.     Patients should not proceed to emergency laparotomy unless an exhaustive effort has been made to localize the source of bleeding using radiologic and/or endoscopic modalities.
6.     Restrictive red blood cell (RBC) thresholds (Hb trigger 70 g/L and Hb concentration target of 70-90 g/L post transfusion) should be used in clinically stable patients who need RBC transfusion. The trigger and target should be 80 g/L and 100 g/L, respectively in patients with a history of cardiovascular disease.
7.     Interrupting warfarin therapy at presentation is recommended. In patients with low thrombotic risk, warfarin should be restarted at 7 days after hemorrhage. In patients with 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, low molecular weight heparin (LMWH) should be considered at 48 hours after the bleeding.
8.     Permanently discontinue aspirin for primary prophylaxis of cardiovascular events. But, restart aspirin for secondary prevention, if stopped, as soon as hemostasis is achieved. 
9.     Routine stopping of dual antiplatelet therapy with a P2Y12 receptor antagonist and aspirin is not recommended in patients with coronary stents in situ; a cardiologist should be part of the management team. Continue aspirin if P2Y12 receptor antagonist is interrupted if unstable hemorrhage; restart P2Y12 receptor antagonist within 5 days.
10.  Direct oral anticoagulant therapy should be interrupted at presentation. Treatment with inhibitors such as idarucizumab or andexanet should be considered for life-threatening hemorrhage in patients on direct oral anticoagulants. Restarting direct oral anticoagulant drug treatment at a maximum of 7 days after the bleeding.

(Source: Oakland K, Chadwick G, East JE, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut. 2019 May;68(5):776-789)

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

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