ACG revamps guidelines for managing acute lower GI bleeding, ‘more data is needed’
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The ACG has issued revised guidelines for the management of patients with acute lower gastrointestinal bleeding, which include new recommendations for risk stratification and reversal agents for patients on anticoagulants.
“Lower gastrointestinal bleeding is one of the leading causes of hospitalization in the United States due to a digestive disorder,” Neil Sengupta, MD, associate professor of gastroenterology at University of Chicago Medicine, told Healio. “The prior ACG guideline on this topic was published in 2016, and since that time there have been several updates to this field. The ACG felt it important to provide an updated, evidence-based clinical practice guideline on this topic for practicing clinicians.”
The new guidelines, which recently were published in The American Journal of Gastroenterology, provide a review of epidemiology and risk factors for onset of lower GI bleeding (LGIB), initial patient assessment and the role of risk stratification, as well as resuscitation strategies, reversal of coagulopathy and diagnostic testing.
“These guidelines provide an evidence-based framework for the management of a hospitalized patient with LGIB,” Sengupta said. “We provide 12 recommendations, for which the evidence was reviewed using the [Grading of Recommendations, Assessment, Development and Evaluation] framework, as well as a list of 10 key concepts which cover topics important to the management of LGIB but not appropriate for GRADE, given the structure of the topic or a lack of available data.”
Highlights from the updated recommendations include:
The use of risk stratification tools, such as the Oakland score, to identify low-risk patients with LGIB for early discharge and outpatient evaluation. Risk scores should supplement clinical judgement.
Patients on vitamin K antagonists with life-threatening LGIB and an international normalized ratio (INR) that exceeds therapeutic range should undergo reversal. Due to the rapidity of INR reduction, four-factor prothrombin complex concentrate is preferred to fresh frozen plasma to prevent stroke in nonvalvular atrial fibrillation.
Patients on direct oral anticoagulants who present with life-threatening LGIB and do not respond to initial resuscitation and cessation of the anticoagulant alone should undergo reversal. Targeted reversal agents, such as idarucizumab for dabigatran and andexanet alfa for apixaban and rivaroxaban, should be used if the direct oral anticoagulant was taken within 24 hours.
CT angiography (CTA) should be performed as the initial diagnostic test among patients with ongoing hemodynamically significant hematochezia. Those whose CTA demonstrates extravasation must be referred to interventional radiology for transcatheter arteriography and possible embolization.
Patients who require a colonoscopy should undergo a nonemergent inpatient procedure as urgent colonoscopy had not been proven to improve clinical outcomes.
Following cessation of LGIB, patients should resume anticoagulation to decrease the risk for post-bleeding thromboembolism and mortality.
“Additional research is needed in several areas, as there is a lack of high-quality data in general, particularly randomized controlled trials, to help guide the management of LGIB,” Sengupta said. “First, more data is needed in general to identify more low-risk patients who can either be managed as an outpatient or be managed conservatively without an inpatient colonoscopy. Second, clarification on which patients benefit from a CTA vs. a prompt inpatient colonoscopy is needed.”
He continued, “Finally, further data on the appropriate role and timing of reversal agents vs. conservative management for patients on anti-thrombotic medications is needed.”
Perspective
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John Vargo, MD, MPH, MASGE
The guidelines represent a rigorous methodological approach to the data and make a great primer for anyone looking to improve their knowledge base for the diagnosis, evaluation and treatment of lower GI bleeding.
It appears that the days of the urgent colonoscopies are over. Urgent colonoscopy did not improve rebleeding rate or mortality, so it makes sense to have optimal preparation and staffing available in a more controlled environment.
For those patients who are hemodynamically unstable, the guidelines recommend CT angiography as a first line study, followed by angiography if extravasation is identified. This is a potential departure for some practices where a colonoscopy, or perhaps even angiography, would have been considered.
Another important area is the utilization of vitamin K antagonists and direct oral anticoagulants. The authors have recommended not reversing them unless a patient is experiencing severe hemorrhage with ongoing hemodynamic issues that are not corrected by standard resuscitation. For most patients, they may be kept on anticoagulants.
Normalization of the INR is not necessary, and the guidelines recommend an INR threshold of 2.5 and below. This can potentially save time to evaluate and minimize utilization of blood products.
Severe lower GI bleeding is a multidisciplinary event: It usually includes gastroenterologists, intensivists, interventional radiologists and surgeons. It behooves all of us to carefully review these guidelines with our colleagues and optimize care algorithms.
In closing, the authors bring up another important point: There is a dearth of randomized, controlled data for many decision points in these algorithms. This can be an opportunity for clinical researchers across the country to provide prospective, randomized data for some of these decision points.
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