American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in acute lower gastrointestinal bleeding.
Refinessuggested applicable standard· American College of Gastroenterology (ACG), Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline (Sengupta N, Feuerstein JD, Jairath V, Shergill AK, Strate LL, Wong RJ, Wan D; Am J Gastroenterol 118(2):208-231), 2023
Decision at stakethe use of colonoscopy versus CT angiography as the initial diagnostic test for acute lower gastrointestinal bleeding
… For patients with ONGOING HEMODYNAMICALLY SIGNIFICANT hematochezia, ACG SUGGESTS CT angiography as the initial diagnostic test (conditional, low-quality; ~90% sensitivity for source localization, low yield once bleeding is minor or has stopped); if CTA shows extravasation, promptly refer to interventional radiology for transcatheter arteriography and possible embolization (STRONG, moderate-quality). …
From our summary of this standard, unedited — the part the paper bears on. … marks omitted text. Our wording, not the guideline's; read the source for its own text.
Our full summary of this standard
Resuscitate and risk-stratify first. ACG 2023 SUGGESTS (conditional, low-quality evidence) using a risk-stratification tool such as the Oakland score to identify low-risk patients with acute LGIB who are appropriate for early discharge and outpatient evaluation, supplementing, not replacing, clinical judgment. Use a restrictive RBC transfusion strategy with a transfusion threshold of hemoglobin 7 g/dL in hemodynamically stable patients (conditional, low-quality); a higher threshold (~8 g/dL) may be considered in known/active cardiovascular disease. For patients with ONGOING HEMODYNAMICALLY SIGNIFICANT hematochezia, ACG SUGGESTS CT angiography as the initial diagnostic test (conditional, low-quality; ~90% sensitivity for source localization, low yield once bleeding is minor or has stopped); if CTA shows extravasation, promptly refer to interventional radiology for transcatheter arteriography and possible embolization (STRONG, moderate-quality). For patients hospitalized with acute LGIB who REQUIRE inpatient colonoscopy, ACG RECOMMENDS a NONEMERGENT inpatient colonoscopy rather than urgent colonoscopy within 24 hours, because urgent colonoscopy within 24h has not been shown to improve rebleeding or mortality (STRONG, moderate-quality); no specific bowel-prep regimen is superior. Reserve reversal agents for LIFE-THREATENING bleeding that does not respond to initial resuscitation (conditional, very-low-quality): for VKA with an INR substantially above therapeutic range, 4-factor PCC is preferred over FFP; for a DOAC taken within the prior 24 hours, use targeted agents (idarucizumab for dabigatran; andexanet alfa for apixaban/rivaroxaban) when available. After cessation of bleeding, ACG RECOMMENDS resuming anticoagulation, since resumption lowers postbleeding thromboembolism and mortality (STRONG, moderate-quality). For antiplatelet therapy after diverticular hemorrhage: CONTINUE aspirin in patients with established cardiovascular disease (secondary prevention; conditional, low-quality), but DISCONTINUE aspirin used for primary cardiovascular prevention (conditional, low-quality).