International on-line questionnaire about severe lower gastrointestinal bleeding management: Do we have it clear?

Lower gastrointestinal bleeding (LGIH) has traditionally been defined as bleeding distal to the angle of Treitz.1 It is a common and potentially serious condition in our environment, representing 30%–40% of all cases of gastrointestinal bleeding, causing 33–115 hospitalizations/100,000 admissions/year.1, 2 It has a low mortality (1.2%–7.7%) and subsides spontaneously in 80%–90% of cases.1 Among the most common causes of LGIB are colonic diverticulosis, anorectal disease, ischemic colitis, angiodysplasia, inflammatory bowel disease, polyps and cancer.1, 2

The diagnostic and therapeutic strategy in these patients varies according to the severity of the bleeding.1, 2, 3, 4, 5, 6 Various studies have described risk factors associated with poor clinical course in LGIB, including the presence of hemodynamic instability (tachycardia, hypotension, syncope), continuous bleeding, associated comorbidities, age >60 years, elevated creatinine, and anemia.1

Guardiola et al.7 define severe LGIB as persistent rectal bleeding (during the first hours of admission) associated with any of the following characteristics: systolic blood pressure <100 mmHg and heart rate >100 bpm, syncope not explained by another cause, hemoglobin <9 g/dl in the absence of previous chronic anemia or a drop in Hb >2 g/dl. In this document, these criteria have been used to define patients with severe LGIB.

In the case of severe LGIB with hemodynamic instability, an initial upper gastrointestinal endoscopy is recommended, after initial stabilization, since up to 10%–20% of these patients actually present upper gastrointestinal bleeding.1, 5 If it is not possible to perform an endoscopy, abdominal computed tomography angiography (CTA) is the examination of choice in these patients.2, 8, 9

In patients without hemodynamic compromise, colonoscopy is the diagnostic modality of choice due to the therapeutic possibilities it offers.1, 4 However, the results of this exploration are variable, and the optimal moment for performing it is currently controversial.

Thus, in the latest guidelines published by the European Society of Gastrointestinal Endoscopy (ESGE) it is stated that, for the moment, there is no quality evidence to show that early colonoscopy, performed in the first 24 h after presentation, influences patient outcomes.2, 10, 11 However, at the moment, it is not clear if selected patients with acute LGIB could benefit from an early colonoscopy.2

Nevertheless, the American LGIB guidelines recommend that patients with high-risk clinical characteristics and signs or symptoms of continuous bleeding undergo early colonoscopy, under hemodynamically stable conditions and after bowel preparation.12 Likewise, the Japanese guidelines for the management of acute LGIB also recommend performing a colonoscopy in the first 24 h to identify the source of bleeding, as well as performing a therapeutic intervention.13 It should be noted that these guidelines predate the publication of two recent randomized studies,10, 11 which show that early colonoscopy does not reduce the risk of rebleeding, mortality, or the need for transfusion; endoscopy being a procedure with a more diagnostic than therapeutic benefit.

Given the discrepancy of recommendations in the different current clinical practice guidelines, the objective of this study was to find out, through an international online survey, aimed at gastroenterology specialists and residents, about the decision-making of gastroenterologists in the management of patients with severe LGIB.

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