Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 7, 2019; 25(1): 69-84
Published online Jan 7, 2019. doi: 10.3748/wjg.v25.i1.69
Initial management for acute lower gastrointestinal bleeding
Tomonori Aoki, Yoshihiro Hirata, Atsuo Yamada, Kazuhiko Koike
Tomonori Aoki, Atsuo Yamada, Kazuhiko Koike, Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
Yoshihiro Hirata, Division of Advanced Genome Medicine, the Institute of Medical Science, the University of Tokyo, Tokyo 108-8639, Japan
Author contributions: Aoki T drafted the article; Hirata Y critically revised; Yamada A and Koike K prepared the manuscript; all authors read and approved the submitted version of the manuscript.
Supported by the JSPS KAKENHI, No. 18K07995 to AY; the funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflict-of-interest statement: The authors have no conflict of interest to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Yoshihiro Hirata, MD, PhD, Associate Professor, Division of Advanced Genome Medicine, the Institute of Medical Science, the University of Tokyo, 4-6-1 Shirokanedai, Minato-ku, Tokyo 108-8639, Japan.
Telephone: +81-3-64092335 Fax: +81-3-64092336
Received: October 10, 2018
Peer-review started: October 10, 2018
First decision: November 14, 2018
Revised: November 17, 2018
Accepted: November 30, 2018
Article in press: November 30, 2018
Published online: January 7, 2019

Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospital admission. Patients with LGIB often experience persistent or recurrent bleeding and require blood transfusions and interventions, such as colonoscopic, radiological, and surgical treatments. Appropriate decision-making is needed to initially manage acute LGIB, including emergency hospitalization, timing of colonoscopy, and medication use. In this literature review, we summarize the evidence for initial management of acute LGIB. Assessing various clinical factors, including comorbidities, medication use, presenting symptoms, vital signs, and laboratory data is useful for risk stratification of severe LGIB, and for discriminating upper gastrointestinal bleeding. Early timing of colonoscopy had the possibility of improving identification of the bleeding source, and the rate of endoscopic intervention, compared with elective colonoscopy. Contrast-enhanced computed tomography before colonoscopy may help identify stigmata of recent hemorrhage on colonoscopy, particularly in patients who can be examined immediately after the last hematochezia. How to deal with nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents after hemostasis should be carefully considered because of the risk of rebleeding and thromboembolic events. In general, aspirin as primary prophylaxis for cardiovascular events and NSAIDs were suggested to be discontinued after LGIB. Managing acute LGIB based on this information would improve clinical outcomes. Further investigations are needed to distinguish patients with LGIB who require early colonoscopy and hemostatic intervention.

Keywords: Lower gastrointestinal bleeding, Predictive model, Colonoscopy, Computed tomography, Medication

Core tip: Several concerns exist when managing acute lower gastrointestinal bleeding (LGIB). Fortunately in recent years, novel findings in the acute LGIB setting have accumulated with respect to predictive scores for severe bleeding, the clinical significance of contrast-enhanced computed tomography before colonoscopy, the utility of early colonoscopy, and the management of direct-acting oral anticoagulants. Here, we review evidence for the initial management of acute LGIB.