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Lower GI Bleeding Management (ACG 2023)

Lower GI Bleeding Management (ACG 2023): START: Acute Lower GI Bleeding → Initial Assessment & Resuscitation → Hemodynamically Stable? → Hemodynamically...

Pathway Overview

15 steps

Algorithm Steps

15 total

  1. 01Start

    START: Acute Lower GI Bleeding

    Hematochezia or maroon stool

  2. 02Action

    Initial Assessment & Resuscitation

    Stabilize patient

    • 2 large-bore IVs
    • Type and screen/crossmatch
    • CBC, BMP, coags, LFTs
    • Rectal exam to confirm hematochezia
    • Consider NG tube/EGD if brisk bleeding (r/o upper source)
  3. 03Decision

    Hemodynamically Stable?

    Assess stability

    • UNSTABLE: SBP <90, HR >100, signs of shock
    • STABLE: Normal vitals, no active bleeding
  4. 04Warning

    Hemodynamically Unstable

    Aggressive resuscitation

    • Crystalloid resuscitation
    • Blood transfusion (target Hgb ≥7, or ≥8 if CAD)
    • Consider massive transfusion if ongoing
    • Correct coagulopathy
    • Rule out upper GI source with NG aspirate or EGD
  5. 05Decision

    Colonoscopy Timing

    Based on risk and stability

    • URGENT (<24h): Hemodynamic instability, high-risk features
    • ELECTIVE (24-72h): Stable, low-risk patients
  6. 06Action

    Bowel Preparation

    Prep before colonoscopy

    • Polyethylene glycol-based prep (4-6L over 3-4 hrs)
    • NG tube if unable to tolerate oral
    • Adequate prep improves diagnostic yield
  7. 07Action

    Colonoscopy

    Diagnostic and therapeutic

    • Identify bleeding source
    • Common sources: Diverticulosis, angiodysplasia, hemorrhoids, neoplasm, colitis
    • Endoscopic therapy if active bleeding or stigmata
  8. 08Decision

    Bleeding Source Identified?

    Colonoscopy findings

  9. 09Action

    Endoscopic Therapy

    If active bleeding or stigmata

    • Clips, thermal coagulation, or injection
    • Combination therapy for high-risk lesions
    • Tattoo lesion for localization if surgery needed
  10. 10Decision

    Rebleeding?

    Monitor for recurrence

  11. 11Warning

    Angiography or Surgery

    For refractory bleeding

    • CTA to localize if bleeding rate >0.5 mL/min
    • Angioembolization if source identified
    • Surgery if angiography fails or unavailable
  12. 12Outcome

    Discharge

    Stable, no rebleeding

    • Address underlying cause
    • Review anticoagulation/antiplatelet
    • GI follow-up
    • Return precautions
  13. 13Action

    No Source Identified

    Further workup

    • If ongoing bleeding: CT angiography or tagged RBC scan
    • Capsule endoscopy for occult/obscure bleeding
    • Consider upper endoscopy if not done
  14. Path rejoins step 10Shared downstream outcome
  15. 14Action

    Risk Stratification

    Identify high-risk features

    • Oakland Score recommended
    • HIGH RISK: Hemodynamic instability, ongoing bleeding, Hgb <7, comorbidities, anticoagulation
    • LOW RISK: Oakland ≤8, no high-risk features
  16. 15Action

    Low Risk (Oakland ≤8)

    May consider outpatient management

    • Outpatient colonoscopy within 7 days
    • Discharge with clear instructions
    • Return if recurrent bleeding
  17. Path rejoins step 05Shared downstream outcome

Guideline Source

ACG Clinical Guideline: Management of Patients With Acute Lower GI Bleeding 2023

DOI: 10.14309/ajg.0000000000002297View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Does not address obscure GI bleeding in detail
  • Risk stratification should be formalized with validated scores
  • Colonoscopy timing depends on local resources
  • Anticoagulation management requires multidisciplinary input

Contraindicated Populations

pediatric

Applicable Regions

USEUGlobal

US: ACG 2023 is current standard

Version 1Next review: 2028-01-01

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Frequently Asked Questions

What is the Lower GI Bleeding Management (ACG 2023)?

The Lower GI Bleeding Management (ACG 2023) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on ACG Clinical Guideline: Management of Patients With Acute Lower GI Bleeding 2023.

What guideline is the Lower GI Bleeding Management (ACG 2023) based on?

This algorithm is based on ACG Clinical Guideline: Management of Patients With Acute Lower GI Bleeding 2023 (DOI: 10.14309/ajg.0000000000002297).

What are the limitations of the Lower GI Bleeding Management (ACG 2023)?

Known limitations include: Does not address obscure GI bleeding in detail; Risk stratification should be formalized with validated scores; Colonoscopy timing depends on local resources; Anticoagulation management requires multidisciplinary input. Individual patient factors may require deviation from these recommendations.

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