ACG updates its guideline on acute lower GI bleeding

The American College of Gastroenterology (ACG) now recommends risk stratification to identify patients who can be discharged early and advises on the use of anticoagulant reversal agents, among other changes.

The American College of Gastroenterology recently updated its guideline on management of patients with acute lower GI bleeding.

The new recommendations include several changes from the previous version, published in 2016. Among these is the suggestion that clinicians use risk stratification tools (e.g., Oakland score ≤8) to identify low-risk patients with lower GI bleeding who are appropriate candidates for early discharge and outpatient diagnostic evaluation. Clinicians should use risk scores to supplement but not replace clinical judgment, the guideline noted.

The guideline also newly advised clinicians on use of reversal agents in patients with life-threatening lower GI bleeding who are on vitamin K antagonists or direct oral anticoagulants and suggested CT angiography as the initial diagnostic test in patients with ongoing hemodynamically significant hematochezia. Clinicians should promptly refer patients whose CT angiography demonstrates extravasation to interventional radiology for transcatheter arteriography and possible embolization, the guideline noted.

The guideline recommended colonoscopy for most patients hospitalized with lower GI bleeding because of its value in detecting a source of bleeding but added that most should be nonurgent, since studies have not shown that performing an urgent colonoscopy within 24 hours of presentation improves important clinical outcomes such as rebleeding.

The guideline also suggested a restrictive strategy of red blood cell transfusion (threshold of hemoglobin level of 7 g/dL) in hemodynamically stable patients with lower GI bleeding and recommended against administration of antifibrinolytic agents such as tranexamic acid.

The guideline also addressed medication after hospitalization for diverticular hemorrhage, recommending discontinuation of nonaspirin NSAIDs and aspirin for primary cardiovascular prevention. In patients with an established history of cardiovascular disease, the guideline suggested continuing aspirin. Clinicians should re-evaluate the risks and benefits of continuing nonaspirin antiplatelets such as P2Y12 receptor antagonists in a multidisciplinary setting, according to the guideline, which was published in the February American Journal of Gastroenterology.