Basildon EM Handbook 2018

Lower gastrointestinal bleeding

Lower gastrointestinal bleeding (LGIB) is a frequent cause of hospital admission and is a factor in hospital morbidity and mortality. LGIB is often overshadowed by upper GI bleeding (UGIB) as it generally has less severe effects. However it can on occasions cause serious haemodynamic instability.

Eitiology and epidemiology

The most common causes of bleeding are diverticular disease, IBD, and anorectal diseases. LGIB is more common in the elderly than in younger people, because diverticulosis and vascular disease are more common in these groups.

Emergency management

•Abdominal profile bloods with clotting and group / screen.

•Good IV access unless there is a strong suspicion of trivial bleed. Minimum 18G and avoid unnecessary use of ACF. Remember to check external jugulars. Consider early central access (e.g. Vascath) if the patient’s veins are poor and they are bleeding ++

•Alternatively, 14G angiocath (or even a 14G cannula in a thin patient) in a femoral vein works well.

•If the patient is shocked; prescribe at least 2 units flying-squad while matched units are being prepared. There isn’t much value in fluids.

•Appropriate investigation is up to the surgeon on call. Usually CT angiography if the patient requires admission.

 Key point: the basics are essential. Issues arising from sick GI bleeders are rarely due to a lack of sophisticated monitoring or investigation--they are usually due to a lack of good IV access, and late transfusion.

Considerations for admission and discharge

A lot of of LGI bleeding is discharged from the ED. Unfortunately there is no Rockall score or similar for guidance. SIGN have produced the following (slightly vague) pointers

Consider discharge if

•age <60 years, and;

•no evidence of haemodynamic compromise, and;

•no evidence of gross rectal bleeding, and;

•an obvious anorectal source of bleeding on rectal examination/sigmoidoscopy.

Consider admisison if

•age =>60 years, or;

•haemodynamic disturbance (HR>90, SBP < 110), or;

•evidence of gross rectal bleeding, or;

•taking aspirin or an NSAID, or;

•significant comorbidity.

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