Lower GI hemorrhageMANAGEMENT

GASTROINTESTINAL PRESENTATIONS · 10 SECTIONS

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421 items

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01Approach to the Critical Patient/attcp81

Triage and immediate priorities

›Initial stabilization

›Hemodynamic instability triggers

›SBP <90 mmHg

›MAP <65 mmHg

›HR >120 beats/min

›Shock index >1.0

›Altered mental status

›Ongoing brisk hematochezia

›Resuscitation setting

›Resuscitation bay for instability

›Early senior support

›Vascular access

›Two large-bore peripheral IVs

›If poor access, intraosseous access

›If severe shock, central venous access

›Monitoring

›Continuous ECG

›Continuous pulse oximetry

›Noninvasive BP cycling q2-5 min

›If ongoing shock, arterial line

›Airway and ventilation

›If inability to protect airway, RSI

›If massive ongoing bleeding with aspiration risk, early intubation

›Circulatory targets

›MAP target 65 mmHg

›Urine output target 0.5 mL/kg/hour

›Mental status normalization target

›Early hemorrhage control strategy

›Bleeding localization priorities

›If unstable or active brisk hematochezia, CT angiography first-line

›If stable with continued bleeding, colonoscopy after prep

›If recurrent or ongoing bleeding with positive CTA, interventional radiology

›Consultation triggers

›GI for suspected lower GI source requiring endoscopy

›Interventional radiology for positive CTA or ongoing brisk bleeding

›Surgery for refractory bleeding or ischemia or perforation concern

Transfusion and massive hemorrhage pathway

›Blood product strategy

›Packed red blood cells

›Restrictive threshold Hb <70 g/L in most patients

›Higher threshold Hb <80 g/L if active ischemic heart disease or persistent shock

›Massive transfusion protocol

›If ongoing hemodynamic instability with suspected massive bleeding, activate MTP

›Balanced ratio strategy per local protocol

›Platelets

›Target >50 x10^9/L in active bleeding

›Target >100 x10^9/L if planned high-risk endoscopic therapy

›Fibrinogen replacement

›If fibrinogen <1.5 g/L, cryoprecipitate or fibrinogen concentrate per protocol

›Calcium repletion

›If massive transfusion, calcium chloride IV bolus per protocol

›Ionized calcium target within normal range

Antithrombotic and anticoagulant management

›Anticoagulant and antiplatelet triage

›Medication reconciliation

›Warfarin

›Apixaban

›Rivaroxaban

›Edoxaban

›Dabigatran

›Heparin infusion

›Low molecular weight heparin

›Aspirin

›Clopidogrel

›Ticagrelor

›Prasugrel

›Reversal decision points

›Life-threatening bleeding definition

›Hemodynamic instability

›Ongoing bleeding requiring transfusion

›Hb drop >20 g/L with ongoing bleeding

›Need for emergent procedure

›If life-threatening bleeding, reversal based on agent and timing

›If non-life-threatening bleeding, individualized hold strategy

Key concepts

›Lower GI hemorrhage framework

›Definition

›Bleeding distal to ligament of Treitz

›Hematochezia common

›Melena possible with right-sided colonic bleeding

›High-risk patterns

›Painless large-volume hematochezia suggests diverticular bleeding

›Recurrent maroon stools suggests proximal colonic or small bowel source

›Pain with bleeding suggests ischemic or inflammatory colitis

02History/hx52

Presentation and course

›Bleeding characterization

›Stool appearance

›Bright red blood per rectum

›Maroon stools

›Black stools

›Blood on tissue only

›Quantity and frequency

›Single episode

›Recurrent episodes

›Continuous bleeding

›Associated symptoms

›Syncope or presyncope

›Dizziness

›Chest pain

›Dyspnea

›Abdominal pain

›Diarrhea

›Fever

›Timeline and triggers

›Onset time

›Recent bowel prep or colonoscopy

›Recent polypectomy

›Recent NSAID use

›Recent antibiotic exposure

›Risk factors and comorbidities

›Prior GI bleeding

›Known diverticulosis

›Known angiodysplasia

›Known inflammatory bowel disease

›Known colorectal cancer or polyps

›Atherosclerotic disease

›Chronic kidney disease

›Cirrhosis

›Heart failure

›Atrial fibrillation

›Medication and substance history

›Anticoagulants

›Antiplatelets

›NSAIDs

›SSRIs

›Alcohol use

›Infectious and exposure context

›Recent travel

›Sick contacts

›Food exposures

›Immunosuppression

PITFALLS

›Diagnostic pitfalls

›Hematochezia with hemodynamic instability as possible upper GI bleeding

›History of peptic ulcer disease

›Liver disease and variceal risk

›Normal initial Hb with acute bleeding

›Underestimation of bleeding with intermittent passage

03Physical Exam/exam23

Targeted exam priorities

›Vital signs and perfusion

›Orthostatic vitals

›Capillary refill

›Skin mottling

›Mental status

›Cardiopulmonary exam

›Signs of heart failure

›New murmur

›Ischemic symptoms

›Abdominal exam

›Focal tenderness

›Peritoneal signs

›Distension

›Bowel sounds

›Rectal and perianal exam

›Gross blood

›Melena

›Hemorrhoids

›Anal fissure

›Mass

PITFALLS

›Exam pitfalls

›Absence of abdominal tenderness does not exclude ischemic colitis

›Hemorrhoids may coexist with proximal significant bleeding

04Differential Diagnosis/ddx34

Life-threatening and high-risk causes

›High-risk etiologies

›Diverticular hemorrhage ICD-10 K57.31

›Painless large-volume hematochezia

›Angiodysplasia of colon ICD-10 K55.20

›Recurrent intermittent bleeding

›Ischemic colitis ICD-10 K55.9

›Abdominal pain with bloody diarrhea

›Colorectal malignancy ICD-10 C18-C20

›Weight loss

›Iron deficiency anemia

›Post-polypectomy bleeding ICD-10 K91.840

›Recent colonoscopy with intervention

›Inflammatory bowel disease flare ICD-10 K50.- K51.-

›Chronic diarrhea

›Tenesmus

›Severe infectious colitis ICD-10 A04.- A09

›Fever

›Exposure risks

›Aortoenteric fistula ICD-10 I77.2

›Prior aortic graft

›Sentinel bleed

Mimics and lower-risk causes

›Common mimics

›Hemorrhoids ICD-10 I84.-

›Blood on tissue

›Minimal systemic symptoms

›Anal fissure ICD-10 K60.2

›Pain with defecation

›Radiation proctitis ICD-10 K62.7

›Prior pelvic radiation

›Proctitis ICD-10 K62.89

›Rectal pain

›Discharge

›Small bowel bleeding ICD-10 K92.2

›Negative upper and lower endoscopy with ongoing bleeding

05Laboratory Tests/lt34

Initial labs and interpretation

›Baseline hemorrhage evaluation

›Complete blood count for bleeding severity

›Hb trend compared with baseline

›Platelet count for procedural planning

›Coagulation profile for reversal decisions

›INR for warfarin effect

›aPTT for heparin effect

›Fibrinogen for massive bleeding physiology

›Type and screen and crossmatch

›If active bleeding, type and cross for multiple units

›Electrolytes and renal function

›Sodium mmol/L

›Potassium mmol/L

›Creatinine for contrast safety and dosing

›Venous blood gas if shock

›Lactate mmol/L

›pH

›Liver tests if chronic liver disease risk

›ALT

›AST

›Bilirubin

›Albumin

Targeted and conditional labs

›Etiology-directed labs

›Stool testing for suspected infectious colitis

›C difficile toxin or PCR

›Stool culture or multiplex PCR per local availability

›Inflammatory markers for colitis pattern

›CRP

›Pregnancy test for reproductive potential

›Serum beta-hCG

PITFALLS

›Lab pitfalls

›Early Hb may be falsely reassuring in acute hemorrhage

›INR does not quantify DOAC activity

›Lactate may be normal early in ischemic colitis

06Diagnostic Tests/dt58

Scoring Systems

›Risk stratification tools

›Oakland score for safe discharge consideration

›Age component

›Sex component

›Prior lower GI bleed admission

›Digital rectal exam blood

›Heart rate

›Systolic blood pressure

›Hemoglobin g/L

›Discharge consideration at low score with no ongoing bleeding and stable vitals

›NOBLADS score for severe lower GI bleeding risk

›NSAID use

›No diarrhea

›No abdominal tenderness

›Systolic blood pressure low

›Antiplatelet use

›Albumin low

›Charlson comorbidity index high

›Syncope

MRI

›Limited role in acute lower GI hemorrhage

›Indications

›Suspected perianal Crohn disease complications when stable

›Pelvic source evaluation when stable

›Constraints

›Not suitable for hemodynamically unstable bleeding

›Limited acute bleeding localization performance

›CT-based localization and complications

›CT angiography abdomen and pelvis

›Indications

›Ongoing brisk hematochezia

›Hemodynamic instability

›Inability to tolerate bowel prep

›Protocol considerations

›Noncontrast phase if concern for high attenuation stool

›Arterial phase for extravasation

›Portal venous phase for delayed bleeding

›Interpretation pearls

›Active extravasation into bowel lumen

›Diverticulosis distribution

›Colitis pattern

›Mesenteric ischemia findings

›Downstream actions

›If positive extravasation, interventional radiology embolization pathway

›If negative with ongoing bleeding, colonoscopy after prep or nuclear scan based on local resources

›CT abdomen and pelvis with IV contrast

›Indications

›Suspected ischemic colitis or perforation

›Suspected malignancy complications

Ultrasound (or US)

›Point-of-care ultrasound integration

›Shock evaluation

›Cardiac function assessment

›Pericardial effusion

›IVC size and collapsibility

›Volume status adjunct

›Lung B-lines for fluid overload risk

›Abdominal adjunct

›Free fluid assessment

›Aortic aneurysm screen in older patients with collapse

07Disposition/dispo23

Level of care decisions

›Admission criteria

›Hemodynamic instability

›Ongoing bleeding in ED

›Need for transfusion

›Significant comorbidities

›Anticoagulant reversal required

›High-risk scores

›ICU criteria

›MTP activation

›Vasopressor requirement

›Persistent lactate elevation

›Active bleeding with repeated transfusion

›Transfer criteria

›No endoscopy capability for urgent colonoscopy

›No interventional radiology for embolization

›No surgical backup for refractory bleeding

Discharge criteria

›Low-risk discharge pathway

›Hemodynamic stability without orthostasis

›No further bleeding during observation

›Hb stable on serial checks

›Reliable follow-up within 7-14 days

›Clear return precautions

›Consider low Oakland score support

08Treatment/t67

General measures and supportive care

›Immediate supportive care

›NPO while active bleeding or pending procedures

›IV crystalloid for initial shock bridge

›Early PRBC transfusion for hemorrhagic shock

›Avoid routine prophylactic antibiotics unless specific indication

›Avoid routine tranexamic acid for GI bleeding due to thromboembolic risk concern

Anticoagulant and antiplatelet reversal

›Warfarin-associated bleeding

›Reversal bundle

›Four-factor PCC IV per weight and INR protocol

›If INR elevated with life-threatening bleed, immediate PCC

›Repeat INR after PCC per protocol

›Vitamin K IV 10 mg

›Slow infusion to reduce reaction risk

›Dabigatran-associated bleeding

›Specific reversal

›Idarucizumab IV 5 g

›Two 2.5 g doses

›Consider repeat dosing if rebound and ongoing bleeding

›Factor Xa inhibitor-associated bleeding

›Reversal options

›Andexanet alfa IV per protocol if available

›Dose based on agent and last dose timing

›Thrombosis monitoring plan

›Four-factor PCC IV 50 units/kg if andexanet unavailable

›Max dose per protocol

›Heparin-associated bleeding

›Protamine sulfate IV

›Dose based on heparin exposure timing

›Infusion rate limitation to reduce hypotension

›Antiplatelet-associated bleeding

›Hold strategy

›Hold P2Y12 inhibitor during active life-threatening bleed when feasible

›Continue aspirin for secondary prevention if possible

›Platelet transfusion

›Consider if life-threatening bleeding with planned urgent procedure

›Avoid routine transfusion for aspirin alone without procedural need

Endoscopic therapy pathway

›Colonoscopy-based management

›Timing strategy

›If ongoing bleeding but stable, early colonoscopy after rapid bowel prep

›If bleeding stopped, inpatient or expedited outpatient colonoscopy based on risk

›Bowel preparation

›Polyethylene glycol electrolyte solution

›High-volume split dosing to clear effluent

›Nasogastric tube administration if unable to drink

›Endoscopic hemostasis options

›Through-the-scope clips

›Diverticular stigmata

›Visible vessel

›Thermal coagulation

›Angiodysplasia

›Epinephrine injection as adjunct

›Not as sole definitive therapy

Interventional radiology and surgical therapy

›Angiography and embolization

›Indications

›Positive CTA extravasation

›Persistent bleeding with hemodynamic compromise

›Embolization principles

›Superselective embolization to reduce ischemia risk

›Post-embolization monitoring for ischemic colitis

›Surgical management

›Indications

›Refractory massive bleeding despite endoscopy and IR

›Suspected bowel ischemia with peritonitis

›Aortoenteric fistula concern

›Localization importance

›Segmental colectomy if localized source

›Subtotal colectomy if uncontrolled and nonlocalized

09Special Populations/sp35

Pregnancy

›Pregnancy-specific considerations

›Common etiologies

›Hemorrhoids

›Anal fissure

›Inflammatory bowel disease flare

›Imaging considerations

›Avoid ionizing radiation when possible

›If life-threatening bleeding, CTA acceptable with shared decision-making

›Medication considerations

›Avoid teratogenic drugs

›Anticoagulant reversal coordination with obstetrics

Geriatric

›Older adult considerations

›High-prevalence etiologies

›Diverticular hemorrhage

›Angiodysplasia

›Colorectal cancer

›Comorbidity risk

›Lower physiologic reserve

›Higher transfusion risk for volume overload

›Medication burden

›Anticoagulant and antiplatelet polypharmacy

›Renal dysfunction affecting DOAC clearance

Pediatrics

›Pediatric considerations

›Age-specific etiologies

›Anal fissure in infants

›Milk protein allergy in infants

›Intussusception with currant jelly stool

›Meckel diverticulum with painless bleeding

›Juvenile polyp with intermittent bleeding

›Resuscitation differences

›Weight-based blood products

›Early pediatric consultation

›Diagnostic priorities

›Meckel scan for suspected Meckel diverticulum

›Ultrasound for intussusception

10Background/b14

Epidemiology

›Epidemiology basics

›Frequency

›Lower GI bleeding common cause of hospitalization in adults

›Incidence increases with age

›Common adult etiologies

›Diverticular bleeding

›Angiodysplasia

›Ischemic colitis

›Outcomes

›Many episodes self-limited

›Rebleeding risk significant in diverticular and angiodysplasia sources

Pathophysiology

›Mechanisms by etiology

›Diverticular hemorrhage

›Ru

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 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.