The key recommendations from the 2021 European Society of Gastrointestinal Endoscopy ESGE guidelines that can be helpful in practice are penned down in this article.

Lower gastrointestinal bleeding 

Due to the great vascularisation of the gastrointestinal (GI) tract's surface area, any acute damage to the GI tract may result in GI bleeding. Any age group should seek prompt medical attention if they have gastrointestinal bleeding. Lower gastrointestinal bleeding (LGIB) is described as recent onset blood loss from the distal location of the Treitz ligament at the duodenojejunal junction.

Guidelines from ESGE

Following are the latest guidelines from the European Society of Gastrointestinal Endoscopy ESGE:

1. According to the ESGE, the initial evaluation of patients presenting with acute lower gastrointestinal bleeding should include the following: a history of co-morbidities and bleeding-promoting medications; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can supplement, but not substitute for, clinician judgment.
2. ESGE suggests that clinicians use an Oakland score of 8 points to guide their choice to discharge a patient for outpatient evaluation when they appear with a self-limited bleed and no unf clinical characteristics.
3. ESGE advises a limiting red blood cell transfusion approach in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular illness, with a haemoglobin threshold of 7g/dL triggering red blood cell transfusion. A target haemoglobin concentration of 7–9g/dL is recommended post-transfusion.
4. ESGE proposes a more liberal red blood cell transfusion approach in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular illness, with a hemoglobin threshold of 8 g/dL triggering red blood cell transfusion. A goal haemoglobin concentration of 10 g/dL is desired posttransfusion.
5. ESGE advises that patients with significant acute lower gastrointestinal bleeding get colonoscopy during their hospital stay since there is no high-quality evidence that colonoscopy done early improves patient outcomes.
6. ESGE recommends that patients with hemodynamic instability and suspected continuous bleeding receive computed CT angiography prior to endoscopic or radiologic therapy to localise the bleeding location.
7. ESGE suggests discontinuing vitamin K antagonists in patients who have experienced significant lower gastrointestinal bleeding and treating their coagulopathy by the degree of the bleeding and their thrombotic risk. We propose intravenous vitamin K and four-factor prothrombin complex concentrate PCC in patients with hemodynamic instability, or fresh frozen plasma in the absence of PCC.
8. ESGE advises temporarily discontinuing direct oral anticoagulants in individuals with significant lower gastrointestinal bleeding upon presentation.
9. ESGE does not advocate discontinuing aspirin in individuals who are already on a low dosage of aspirin for secondary cardiovascular protection. If low dosage aspirin is discontinued, it should be restarted within 5 days, ideally sooner if hemostasis is established or there are no additional signs of bleeding.
10. ESGE does not advocate quitting dual antiplatelet medication (low-dose aspirin with a P2Y12 receptor antagonist) without consulting with a cardiology specialist. While it is suggested to continue taking aspirin, the P2Y12 receptor antagonist may be continued or temporarily discontinued depending on the degree of bleeding and the risk of ischemic stroke. If the P2Y12 receptor antagonist is discontinued, it should be reintroduced within 5 days if still recommended.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.