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Lower Gastrointestinal Bleeding and HematocheziaAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

612 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Abdominal Distension Abdominal Pain, Undifferentiated Acute Abdominal Pain (general)Suspected Incarcerated Or Strangulated Hernia Pancreatitis Concern Biliary Colic And Cholecystitis Concern Appendicitis Concern Diverticulitis Concern Rectal Pain And Anorectal Complaints Dysphagia And Food Bolus Impaction Foreign Body Ingestion Refractory Vomiting And Recurrent Vomiting Syndromes Cannabis Associated Hyperemesis Upper Gastrointestinal Bleeding Symptoms (melena)Lower Gastrointestinal Bleeding And Hematochezia Constipation And Obstipation Diarrhea Acute Hepatitis And Jaundice Concern Right Upper Quadrant Pain Epigastric Pain Left Upper Quadrant Pain Right Lower Quadrant Pain Left Lower Quadrant Pain Suprapubic Pain

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx67

Presenting bleeding pattern

›Bleeding pattern

›Hematochezia

›Bright red

›Maroon

›Mixed with stool

›On surface

›Mixed throughout

›Quantity estimate

›Drops on paper

›Bowl turns red

›Clots

›Small

›Large

OPQRST

›OPQRST

›Onset

›First episode

›Recurrent episodes

›Provocation and palliation

›With defecation

›Without defecation

›Quality

›Liquid blood

›Blood streaking

›Region and radiation

›Anal pain location

›Abdominal pain location

02Alarm Features/alarm42

Hemodynamic and shock triggers

›Shock triggers

›Systolic blood pressure less than 90 mmHg

›Persistent after positioning

›Associated altered mental status

›Heart rate 100 or higher

›Rising trend

›With orthostasis

›Orthostatic symptoms

›Presyncope

›Syncope

›Signs of poor perfusion

›Cool clammy skin

›Delayed capillary refill

High risk bleeding contexts

›High risk contexts

›Anticoagulation

›DOAC

›Warfarin

›Known cirrhosis portal hypertension

›Varices history

›Prior GI bleed

›Known aortic stenosis

›Heyde syndrome concern

›Prior angiodysplasia

›Immunocompromised

›Neutropenia

›Transplant

03Medications/meds30

Bleeding and platelet effect

›Bleeding risk meds

›Anticoagulants

›Apixaban

›Rivaroxaban

›Vitamin K antagonist

›Warfarin

›Recent INR variability

›Antiplatelets

›Aspirin

›Clopidogrel

›NSAIDs

›Ibuprofen

›Naproxen

Infection and colitis risk

›Colitis risk meds

›Recent antibiotics

›Fluoroquinolones

›Clindamycin

›Immune therapies

›Checkpoint inhibitors

›Biologics

›Chemotherapy

›Recent cycle

›Neutropenia history

Medication planning constraints

›Constraints

›Contrast nephropathy risk meds

04Diet/diet20

Recent intake and hydration

›Intake and hydration

›Poor oral intake

›Less than 24 hours

›More than 24 hours

›Dehydration indicators

›Thirst

›Reduced urine

›Alcohol exposure

›Heavy recent intake

›Withdrawal risk

Foodborne exposure

›Foodborne exposure

›Undercooked meat

›Ground beef

›Poultry

›Unpasteurized products

›Dairy

›Juices

›Restaurant outbreak context

›Shared meal

›Others ill

05Review of Systems/ros30

Constitutional and infection

›Constitutional

›Fever

›Rigors

›Night sweats

›Weight loss

›Unintentional

›Rapid

›Fatigue

›New

›Progressive

Cardiopulmonary and anemia

›Anemia and cardiopulmonary

›Dyspnea

›Exertional

›At rest

›Chest pain

›Exertional

›Pleuritic

›Palpitations

›New

›With dizziness

GI and rectal symptoms

›GI and rectal

›Change in bowel habits

›New constipation

›New diarrhea

›Mucus in stool

06Collateral History and Family History/chafh17

Collateral and reliability

›Collateral

›Source

›Family

›Caregiver

›Reliability concerns

›Cognitive impairment

›Language barrier

Family history relevant

›Family history

›Colorectal cancer (C18 to C20)

›First degree relative

›Age under 50

›Inflammatory bowel disease

›Ulcerative colitis (K51)

›Crohn disease (K50)

›Bleeding disorders

›Von Willebrand disease (D68.0)

›Hemophilia (D66)

07Risk Factors/rf30

Lower GI bleeding etiologies

›Etiology risk factors

›Diverticulosis risk

›Age older than 60

›Prior diverticular bleed

›Angiodysplasia risk

›Chronic kidney disease (N18)

›Aortic stenosis (I35.0)

›Colorectal malignancy risk

›Iron deficiency history

›Weight loss

Ischemia and vascular risk

›Ischemia risk

›Atherosclerotic disease

›Coronary artery disease (I25)

›Peripheral artery disease (I73.9)

›Low flow states

›Heart failure (I50)

›Recent hypotension

›Hypercoagulable states

›Active cancer (C00 to C97)

›Recent surgery

Infectious and inflammatory risk

›Colitis risk

›Travel

›Recent international

›Rural water exposure

›Sick contacts

08Differential Diagnosis/ddx48

Life threatening

›Life threatening

›Massive lower GI bleed

›Hemodynamic instability

›Rapid hemoglobin fall

›Upper GI bleed with rapid transit (K92.2)

›Melena history

›BUN rise out of proportion

›Ischemic colitis (K55.9)

›Pain then bleeding

›Vascular risk factors

›Aortoenteric fistula (I77.2)

›Prior aortic graft

›Sentinel bleed

›Mesenteric ischemia (K55.0)

›Severe pain out of proportion

›Elevated lactate

Common

›Common

›Diverticular bleeding (K57.3)

›Painless hematochezia

›Large volume

›Hemorrhoids (I84)

›Blood on paper

›No systemic symptoms

›Anal fissure (K60.2)

›Pain with defecation

›Constipation history

09Past Medical History/pmh23

Prior GI evaluation and interventions

›GI history

›Prior colonoscopy

›Diverticulosis

›Polyps

›Prior GI bleeding

›Source identified

›Transfusion history

›GI surgeries

›Colectomy

›Bariatric surgery

Comorbidities affecting management

›Comorbidities

›Chronic kidney disease (N18)

›Baseline creatinine

›Dialysis status

›Chronic liver disease (K76.9)

›Coagulopathy history

›Varices history

›Cardiac disease

›Coronary artery disease (I25)

›Heart failure (I50)

›Bleeding disorders

›Von Willebrand disease (D68.0)

›Thrombocytopenia (D69.6)

10Physical Exam/exam43

Initial appearance and perfusion

›General and perfusion

›Mental status

›Normal

›Altered

›Skin perfusion

›Cool clammy

›Diaphoretic

›Conjunctival pallor

›Present

›Absent

Hemodynamic exam

›Hemodynamic

›Orthostatic vitals

›Symptomatic drop

›Tachycardic response

›Peripheral pulses

›Weak

›Bounding

›JVP and volume status

›Flat

›Elevated

Abdominal exam

›Abdominal

›Tenderness pattern

›Left lower quadrant

›Diffuse

›Peritoneal signs

11Lab Studies/labs36

Core labs for bleeding severity

›Core labs

›CBC

›Hemoglobin trend

›Platelet count

›Type and screen

›Crossmatch threshold local protocol dependent

›Massive transfusion activation criteria local protocol dependent

›Coagulation studies

›INR

›aPTT

›Basic metabolic panel

›Creatinine for contrast planning

›Potassium for transfusion risk

Additional labs by context

›Context labs

›Lactate

›Shock marker

›Mesenteric ischemia support

›LFTs

›Cirrhosis support

›Synthetic dysfunction support

›Venous blood gas

›pH

›Base deficit

›Pregnancy test

›All patients with pregnancy potential

›Imaging selection impact

12Imaging/img37

Scoring Systems

›Risk scores

›Oakland score local protocol dependent

›Low risk supports discharge pathway

›Not for hemodynamically unstable

›Glasgow Blatchford score for possible upper GI source

›Use when upper GI bleed possible

›Not a lower GI specific tool

MRI

›MRI

›MRI enterography

›Crohn disease assessment

›Avoid in unstable bleeding

›Contraindications

›Non MRI compatible device

›Severe claustrophobia

›CT

›CT angiography abdomen pelvis

›Active bleeding localization

›Supports IR embolization planning

›Performance depends on active bleeding at scan time

›False negative if intermittent bleeding

›Reduced yield after large fluid resuscitation

›CT abdomen pelvis with IV contrast

›Colitis evaluation

›Diverticulitis complications

›Contrast risk considerations

13Special Tests/spec20

Bedside evaluation and procedures

›Bedside and procedures

›Anoscopy

›Hemorrhoids visualization

›Fissure visualization

›Proctoscopy or flexible sigmoidoscopy

›Distal colitis assessment

›Limited for proximal sources

›Nasogastric aspirate local protocol dependent

›Possible upper GI source

›Limited negative predictive value

Endoscopy and angiography pathways

›Specialty diagnostics

›Colonoscopy

›Preferred after stabilization and prep

›Lower yield with ongoing massive bleeding without prep

›Tagged RBC scan local protocol dependent

›Intermittent bleeding detection

›Poor anatomic precision compared to CT angiography

›Catheter angiography

›Therapeutic embolization option

›Requires adequate bleeding rate and expertise

14ECG/ecg20

Indications in GI bleeding

›ECG indications

›Chest pain

›Ischemia evaluation

›Demand ischemia risk

›Syncope or presyncope

›Arrhythmia screen

›QT interval baseline

›Significant anemia or shock

›Ischemic changes

›Rate related changes

High risk ECG patterns

›High risk patterns

›ST elevation

›Immediate reperfusion pathway

›Concurrent resuscitation

›New ischemic ST depression

›Demand ischemia support

›Troponin correlation

›Atrial fibrillation with rapid ventricular response

›Trigger worsened bleeding risk context

›Anticoagulation decision complexity

15Assessment/ax30

Problem representation and severity

›Severity

›Suspected lower gastrointestinal bleeding (K92.2)

›Hemodynamic status

›Ongoing bleeding status

›Anemia severity

›Symptomatic anemia features

›Hemoglobin trend

›Transfusion and coagulopathy considerations

›Anticoagulant exposure

›Platelet count

Source localization logic

›Localization

›Likely anorectal source

›Pain with stool

›Small volume bright red

›Likely colonic source

›Large volume painless

›Maroon stool

›Upper GI source not excluded

›Hemodynamic instability disproportionate

›Melena history

Complications to rule out

›Complications

›Shock

›Lactate elevation

›Persistent hypotension

›Sepsis from colitis

16Plan/plan66

Differential Management

›!Lower GI hemorrhage→›!Diverticulitis→›Hemorrhoids (thrombosed)→

First 5 minutes

›First 5 minutes

›Escalate to resuscitation bay if unstable

›Systolic blood pressure less than 90 mmHg

›Altered mental status

›Monitoring

›Continuous pulse oximetry

›Cardiac monitor

›IV access

›Two large bore peripheral IVs

›IO access if IV failure and unstable

›Initial fluids

›Balanced crystalloid bolus 500 mL to 1 L

›Stop boluses if pulmonary edema signs

›Blood products local protocol dependent

›Activate massive transfusion if ongoing shock

›Early type specific or O negative if delay

Transfusion and hemostasis strategy

›Hemostasis strategy

›Restrictive transfusion target when stable

›Hemoglobin under 70 g/L transfuse typical

›Higher threshold with active ischemia local protocol dependent

›Platelet transfusion thresholds local protocol dependent

›Platelets under 50 x 10^9 per L with active bleeding

17Disposition/dispo27

ICU criteria

›ICU criteria

›Ongoing hemodynamic instability

›Vasopressor requirement

›Persistent lactate rise

›Massive transfusion activation

›Ongoing requirement

›Coagulopathy with bleeding

›High risk comorbidity with instability

›Severe aortic stenosis

›Severe coronary disease symptoms

Inpatient and observation criteria

›Inpatient and observation

›Inpatient admission

›Hemoglobin drop with ongoing bleeding

›CT angiography positive finding

›Observation pathway local protocol dependent

›Stable vitals without ongoing bleeding

›Reliable follow up and support

Discharge criteria

›Discharge criteria

›No ongoing bleeding in ED observation period

›Stable vitals

›No orthostasis

›Hemoglobin stable on repeat

›No symptomatic anemia

›No high risk anticoagulation issues

›Clear outpatient plan

18Discharge Instructions/di20

Copy discharge instructions

›Copy discharge instructions

›Today you were seen for bleeding from the rectum

›The most likely cause may be from the lower digestive tract

›Some causes are minor but some can be serious

›Medicines

›Avoid NSAIDs unless your clinician says otherwise

›Take blood thinners only as directed by your prescribing clinician

›Activity

›Rest today

›Avoid heavy lifting if it worsens bleeding

›Follow up

›Primary care or gastroenterology within 1 to 2 weeks

›Earlier follow up if bleeding recurs

›Return to the emergency department now for

›Fainting or near fainting

›Chest pain or shortness of breath

›Large amounts of blood or clots

›Black tarry stools

›Severe or worsening abdominal pain

›Fever or feeling very unwell

19References/r6

Guidelines and key sources

›References

›American College of Gastroenterology guideline on management of acute lower gastrointestinal bleeding, 2016

›British Society of Gastroenterology guideline for acute lower gastrointestinal bleeding, 2019

›European Society of Gastrointestinal Endoscopy guideline on diagnosis and management of acute lower gastrointestinal bleeding, 2021

›American College of Radiology Appropriateness Criteria for gastrointestinal bleeding, updated periodically, local protocol dependent

›Oakland score derivation and validation studies for safe discharge in lower GI bleeding, 2017 to 2018

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Lower Gastrointestinal Bleeding and HematocheziaAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

612 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx67

Presenting bleeding pattern

›Bleeding pattern

›Hematochezia

›Bright red

›Maroon

›Mixed with stool

›On surface

›Mixed throughout

›Quantity estimate

›Drops on paper

›Bowl turns red

›Clots

›Small

›Large

OPQRST

›OPQRST

›Onset

›First episode

›Recurrent episodes

›Provocation and palliation

›With defecation

›Without defecation

›Quality

›Liquid blood

›Blood streaking

›Region and radiation

›Anal pain location

›Abdominal pain location

02Alarm Features/alarm42

Hemodynamic and shock triggers

›Shock triggers

›Systolic blood pressure less than 90 mmHg

›Persistent after positioning

›Associated altered mental status

›Heart rate 100 or higher

›Rising trend

›With orthostasis

›Orthostatic symptoms

›Presyncope

›Syncope

›Signs of poor perfusion

›Cool clammy skin

›Delayed capillary refill

High risk bleeding contexts

›High risk contexts

›Anticoagulation

›DOAC

›Warfarin

›Known cirrhosis portal hypertension

›Varices history

›Prior GI bleed

›Known aortic stenosis

›Heyde syndrome concern

›Prior angiodysplasia

›Immunocompromised

›Neutropenia

›Transplant

03Medications/meds30

Bleeding and platelet effect

›Bleeding risk meds

›Anticoagulants

›Apixaban

›Rivaroxaban

›Vitamin K antagonist

›Warfarin

›Recent INR variability

›Antiplatelets

›Aspirin

›Clopidogrel

›NSAIDs

›Ibuprofen

›Naproxen

Infection and colitis risk

›Colitis risk meds

›Recent antibiotics

›Fluoroquinolones

›Clindamycin

›Immune therapies

›Checkpoint inhibitors

›Biologics

›Chemotherapy

›Recent cycle

›Neutropenia history

Medication planning constraints

›Constraints

›Contrast nephropathy risk meds

04Diet/diet20

Recent intake and hydration

›Intake and hydration

›Poor oral intake

›Less than 24 hours

›More than 24 hours

›Dehydration indicators

›Thirst

›Reduced urine

›Alcohol exposure

›Heavy recent intake

›Withdrawal risk

Foodborne exposure

›Foodborne exposure

›Undercooked meat

›Ground beef

›Poultry

›Unpasteurized products

›Dairy

›Juices

›Restaurant outbreak context

›Shared meal

›Others ill

05Review of Systems/ros30

Constitutional and infection

›Constitutional

›Fever

›Rigors

›Night sweats

›Weight loss

›Unintentional

›Rapid

›Fatigue

›New

›Progressive

Cardiopulmonary and anemia

›Anemia and cardiopulmonary

›Dyspnea

›Exertional

›At rest

›Chest pain

›Exertional

›Pleuritic

›Palpitations

›New

›With dizziness

GI and rectal symptoms

›GI and rectal

›Change in bowel habits

›New constipation

›New diarrhea

›Mucus in stool

06Collateral History and Family History/chafh17

Collateral and reliability

›Collateral

›Source

›Family

›Caregiver

›Reliability concerns

›Cognitive impairment

›Language barrier

Family history relevant

›Family history

›Colorectal cancer (C18 to C20)

›First degree relative

›Age under 50

›Inflammatory bowel disease

›Ulcerative colitis (K51)

›Crohn disease (K50)

›Bleeding disorders

›Von Willebrand disease (D68.0)

›Hemophilia (D66)

07Risk Factors/rf30

Lower GI bleeding etiologies

›Etiology risk factors

›Diverticulosis risk

›Age older than 60

›Prior diverticular bleed

›Angiodysplasia risk

›Chronic kidney disease (N18)

›Aortic stenosis (I35.0)

›Colorectal malignancy risk

›Iron deficiency history

›Weight loss

Ischemia and vascular risk

›Ischemia risk

›Atherosclerotic disease

›Coronary artery disease (I25)

›Peripheral artery disease (I73.9)

›Low flow states

›Heart failure (I50)

›Recent hypotension

›Hypercoagulable states

›Active cancer (C00 to C97)

›Recent surgery

Infectious and inflammatory risk

›Colitis risk

›Travel

›Recent international

›Rural water exposure

›Sick contacts

08Differential Diagnosis/ddx48

Life threatening

›Life threatening

›Massive lower GI bleed

›Hemodynamic instability

›Rapid hemoglobin fall

›Upper GI bleed with rapid transit (K92.2)

›Melena history

›BUN rise out of proportion

›Ischemic colitis (K55.9)

›Pain then bleeding

›Vascular risk factors

›Aortoenteric fistula (I77.2)

›Prior aortic graft

›Sentinel bleed

›Mesenteric ischemia (K55.0)

›Severe pain out of proportion

›Elevated lactate

Common

›Common

›Diverticular bleeding (K57.3)

›Painless hematochezia

›Large volume

›Hemorrhoids (I84)

›Blood on paper

›No systemic symptoms

›Anal fissure (K60.2)

›Pain with defecation

›Constipation history

09Past Medical History/pmh23

Prior GI evaluation and interventions

›GI history

›Prior colonoscopy

›Diverticulosis

›Polyps

›Prior GI bleeding

›Source identified

›Transfusion history

›GI surgeries

›Colectomy

›Bariatric surgery

Comorbidities affecting management

›Comorbidities

›Chronic kidney disease (N18)

›Baseline creatinine

›Dialysis status

›Chronic liver disease (K76.9)

›Coagulopathy history

›Varices history

›Cardiac disease

›Coronary artery disease (I25)

›Heart failure (I50)

›Bleeding disorders

›Von Willebrand disease (D68.0)

›Thrombocytopenia (D69.6)

10Physical Exam/exam43

Initial appearance and perfusion

›General and perfusion

›Mental status

›Normal

›Altered

›Skin perfusion

›Cool clammy

›Diaphoretic

›Conjunctival pallor

›Present

›Absent

Hemodynamic exam

›Hemodynamic

›Orthostatic vitals

›Symptomatic drop

›Tachycardic response

›Peripheral pulses

›Weak

›Bounding

›JVP and volume status

›Flat

›Elevated

Abdominal exam

›Abdominal

›Tenderness pattern

›Left lower quadrant

›Diffuse

›Peritoneal signs

11Lab Studies/labs36

Core labs for bleeding severity

›Core labs

›CBC

›Hemoglobin trend

›Platelet count

›Type and screen

›Crossmatch threshold local protocol dependent

›Massive transfusion activation criteria local protocol dependent

›Coagulation studies

›INR

›aPTT

›Basic metabolic panel

›Creatinine for contrast planning

›Potassium for transfusion risk

Additional labs by context

›Context labs

›Lactate

›Shock marker

›Mesenteric ischemia support

›LFTs

›Cirrhosis support

›Synthetic dysfunction support

›Venous blood gas

›pH

›Base deficit

›Pregnancy test

›All patients with pregnancy potential

›Imaging selection impact

12Imaging/img37

Scoring Systems

›Risk scores

›Oakland score local protocol dependent

›Low risk supports discharge pathway

›Not for hemodynamically unstable

›Glasgow Blatchford score for possible upper GI source

›Use when upper GI bleed possible

›Not a lower GI specific tool

MRI

›MRI

›MRI enterography

›Crohn disease assessment

›Avoid in unstable bleeding

›Contraindications

›Non MRI compatible device

›Severe claustrophobia

›CT

›CT angiography abdomen pelvis

›Active bleeding localization

›Supports IR embolization planning

›Performance depends on active bleeding at scan time

›False negative if intermittent bleeding

›Reduced yield after large fluid resuscitation

›CT abdomen pelvis with IV contrast

›Colitis evaluation

›Diverticulitis complications

›Contrast risk considerations

13Special Tests/spec20

Bedside evaluation and procedures

›Bedside and procedures

›Anoscopy

›Hemorrhoids visualization

›Fissure visualization

›Proctoscopy or flexible sigmoidoscopy

›Distal colitis assessment

›Limited for proximal sources

›Nasogastric aspirate local protocol dependent

›Possible upper GI source

›Limited negative predictive value

Endoscopy and angiography pathways

›Specialty diagnostics

›Colonoscopy

›Preferred after stabilization and prep

›Lower yield with ongoing massive bleeding without prep

›Tagged RBC scan local protocol dependent

›Intermittent bleeding detection

›Poor anatomic precision compared to CT angiography

›Catheter angiography

›Therapeutic embolization option

›Requires adequate bleeding rate and expertise

14ECG/ecg20

Indications in GI bleeding

›ECG indications

›Chest pain

›Ischemia evaluation

›Demand ischemia risk

›Syncope or presyncope

›Arrhythmia screen

›QT interval baseline

›Significant anemia or shock

›Ischemic changes

›Rate related changes

High risk ECG patterns

›High risk patterns

›ST elevation

›Immediate reperfusion pathway

›Concurrent resuscitation

›New ischemic ST depression

›Demand ischemia support

›Troponin correlation

›Atrial fibrillation with rapid ventricular response

›Trigger worsened bleeding risk context

›Anticoagulation decision complexity

15Assessment/ax30

Problem representation and severity

›Severity

›Suspected lower gastrointestinal bleeding (K92.2)

›Hemodynamic status

›Ongoing bleeding status

›Anemia severity

›Symptomatic anemia features

›Hemoglobin trend

›Transfusion and coagulopathy considerations

›Anticoagulant exposure

›Platelet count

Source localization logic

›Localization

›Likely anorectal source

›Pain with stool

›Small volume bright red

›Likely colonic source

›Large volume painless

›Maroon stool

›Upper GI source not excluded

›Hemodynamic instability disproportionate

›Melena history

Complications to rule out

›Complications

›Shock

›Lactate elevation

›Persistent hypotension

›Sepsis from colitis

16Plan/plan66

Differential Management

›!Lower GI hemorrhage→›!Diverticulitis→›Hemorrhoids (thrombosed)→

First 5 minutes

›First 5 minutes

›Escalate to resuscitation bay if unstable

›Systolic blood pressure less than 90 mmHg

›Altered mental status

›Monitoring

›Continuous pulse oximetry

›Cardiac monitor

›IV access

›Two large bore peripheral IVs

›IO access if IV failure and unstable

›Initial fluids

›Balanced crystalloid bolus 500 mL to 1 L

›Stop boluses if pulmonary edema signs

›Blood products local protocol dependent

›Activate massive transfusion if ongoing shock

›Early type specific or O negative if delay

Transfusion and hemostasis strategy

›Hemostasis strategy

›Restrictive transfusion target when stable

›Hemoglobin under 70 g/L transfuse typical

›Higher threshold with active ischemia local protocol dependent

›Platelet transfusion thresholds local protocol dependent

›Platelets under 50 x 10^9 per L with active bleeding

17Disposition/dispo27

ICU criteria

›ICU criteria

›Ongoing hemodynamic instability

›Vasopressor requirement

›Persistent lactate rise

›Massive transfusion activation

›Ongoing requirement

›Coagulopathy with bleeding

›High risk comorbidity with instability

›Severe aortic stenosis

›Severe coronary disease symptoms

Inpatient and observation criteria

›Inpatient and observation

›Inpatient admission

›Hemoglobin drop with ongoing bleeding

›CT angiography positive finding

›Observation pathway local protocol dependent

›Stable vitals without ongoing bleeding

›Reliable follow up and support

Discharge criteria

›Discharge criteria

›No ongoing bleeding in ED observation period

›Stable vitals

›No orthostasis

›Hemoglobin stable on repeat

›No symptomatic anemia

›No high risk anticoagulation issues

›Clear outpatient plan

18Discharge Instructions/di20

Copy discharge instructions

›Copy discharge instructions

›Today you were seen for bleeding from the rectum

›The most likely cause may be from the lower digestive tract

›Some causes are minor but some can be serious

›Medicines

›Avoid NSAIDs unless your clinician says otherwise

›Take blood thinners only as directed by your prescribing clinician

›Activity

›Rest today

›Avoid heavy lifting if it worsens bleeding

›Follow up

›Primary care or gastroenterology within 1 to 2 weeks

›Earlier follow up if bleeding recurs

›Return to the emergency department now for

›Fainting or near fainting

›Chest pain or shortness of breath

›Large amounts of blood or clots

›Black tarry stools

›Severe or worsening abdominal pain

›Fever or feeling very unwell

19References/r6

Guidelines and key sources

›References

›American College of Gastroenterology guideline on management of acute lower gastrointestinal bleeding, 2016

›British Society of Gastroenterology guideline for acute lower gastrointestinal bleeding, 2019

›European Society of Gastrointestinal Endoscopy guideline on diagnosis and management of acute lower gastrointestinal bleeding, 2021

›American College of Radiology Appropriateness Criteria for gastrointestinal bleeding, updated periodically, local protocol dependent

›Oakland score derivation and validation studies for safe discharge in lower GI bleeding, 2017 to 2018

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.