Background: Lower GI bleeding (LGIB) is a fairly common ED presentation, but it may surprise you to learn that there are no UK national guidelines on the acute management of this condition. Who can go home? Who needs admission? What is the best initial management? Thankfully, the British Society of Gastroenterology has recently published a paper covering all of this, and it's a big one: stakeholders include the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists and NHS Blood and Transplant.

 

 

Oakland K, Chadwick G, East J, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut. 2019 Jan;0:1-14

 

 

Summary of recommendations

 

 

Diagnosis:

 

The Oakland score is recommended to risk-stratify patients

Patients with a minor self-limiting bleed (Oakland 8 points or less) can be discharged for urgent outpatient investigation

Patients with a major bleed (Oakland >8 points) should be admitted for colonoscopy on the next available list

Patients who are haemodynamically unstable (shock index >1 after initial resuscitation) should be admitted for urgent CT angiography (CTA)

 

 

Management:

 

Colonoscopy is the preferred initial investigation in most cases of major LGIB as it has the potential for diagnosis and treatment

CTA is preferred over colonoscopy in unstable patients, as it can localise a bleeding source in the upper and lower GI tract and has no requirement for bowel preparation

If no source is identified on CTA, patients should undergo an upper endoscopy (OGD)

Some unstable patients should proceed directly to OGD following senior discussion, as shock is more commonly found in UGIB than LGIB

No patient should proceed to emergency laparotomy unless every effort has been made to localise bleeding by radiological or endoscopic modalities

 

 

Blood transfusion:

 

Patients should be transfused if haemoglobin level is less than 70g/L

Patients with a history of cardiovascular disease should be transfused if haemoglobin is less than 80g/L

 

 

Expert commentary:"This article is really interesting: a useful summary for ourselves and the admitting speciality. The Oakland score looks promising, as it seems to have fairly standard criteria on it." (Dr Robert Tan, ED Consultant)

 

 

More on the Oakland score: The score can be found on MDCalc. It predicts the probability of safe discharge, specifically the absence of rebleeding, transfusion, interventions, readmission or death at 28 days. It is based on 7 variables: age, sex, history of LGIB, blood on PR, heart rate, blood pressure and haemoglobin level. A score of 8 or less corresponds to a 95% probability of safe discharge. The score was derived in a large UK-based multi-centre study (The Lancet, 2017) involving around 2,300 patients. It has not been internationally validated yet.