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New Guideline Recommends Changes in Management of Acute Lower GI Bleeding
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The ACG has released a new clinical guideline on the management of patients with acute lower gastrointestinal bleeding, which provides a number of recommendations regarding initial evaluation and management, the role of colonoscopic and non-colonoscopic diagnostic and therapeutic strategies, and prevention of recurrent bleeding events.
“The latest ACG Guideline on the management of patients with acute lower gastrointestinal bleeding outlines 27 key recommendations for clinicians and grades these recommendations according to the strength of the evidence,” Lisa L. Strate, MD, MPH, FACG, of the division of gastroenterology at University of Washington School of Medicine in Seattle, told Healio Gastroenterology.
Lisa L. Strate
One key change in the updated guideline is that lower packed red blood cell transfusion thresholds are now recommended, Strate said. A hemoglobin threshold of 7g/dL is now recommended, and 9g/dL should be considered if there is severe bleeding, significant comorbid illness like cerebrovascular or cardiovascular disease, or delayed interventions.
The guidelines also “recommend colonoscopy as the initial procedure for nearly all patients presenting with suspected lower gastrointestinal bleeding,” Strate said. The document emphasizes the importance of careful inspection of the colonic mucosa so as not to miss intermittently bleeding lesions, and strongly recommends adequate bowel preparation.
A conditional recommendation is that colonoscopy should be “performed within the first 24 hours of presentation to the hospital in patients with high-risk features and evidence of ongoing bleeding,” Strate said. “High-risk endoscopic stigmata of bleeding including adherent clots and visible vessels should be treated at the time of colonoscopy,” she added. Although the optimal technique has yet to be fully characterized, colonoscopy with endoscopic hemostasis for colonic bleeding is safe and appears to be effective, and the modality should be selected based on the bleeding source, access to the bleeding site and the endoscopist’s experience, according to the document.
The guideline also makes a number of strong recommendations regarding prevention of recurrent lower GI bleeding.
“In the past, aspirin therapy was withheld in patients presenting with lower gastrointestinal bleeding,” Strate said. “However, the new recommendations state that aspirin should not be discontinued in patients with lower gastrointestinal bleeding and established high-risk cardiovascular disease,” based on data showing a similar risk for bleeding and a lower mortality risk in patients receiving aspirin. “Patients on new target-specific anticoagulants or dual antiplatelet agents should be managed by a multidisciplinary team to balance the risk of further bleeding with the risk of thromboembolic events,” Strate said.
Although the quality of existing evidence is low, Strate and her co-author, Ian M. Gralnek, MD, MSHS, chief of the Institute of Gastroenterology and Hepatology at Ha’Emek Medical Center in Israel, wrote that they “strongly endorse some of the recommendations because the potential benefits appear to outweigh the risk of harm.” An algorithm for management of patients presenting with acute lower GI bleed, stratified by bleeding severity, is included in the document. – by Adam Leitenberger
Disclosure: Gralnek reports he has served as a consultant for EndoChoice, Motus GI, and EndoAid GI View, and is a member of the Data Safety Monitoring Board for Intec Pharma.
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