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The American College of Gastroenterology (ACG) has updated guidelines for the management of SGIA to refer to episodes of hematochezia or bright red blood from the rectum originating from a colorectal source (2).Among the various aspects examined: epidemiology and risk factors for onset, initial assessment and the role of risk stratification tools to identify patients at low and high risk of complications.
Current epidemiological scenario
In recent years, the management of patients admitted to SGIA has become more complex, with increasing age and comorbidities of patients, need for more frequent transfusions and longer hospital stays. Epidemiological studies indicate that the incidence of SGIA may be increasing compared to the incidence of upper gastrointestinal bleeding. Possible reasons for the increased incidence of SGIA include the aging population and increased use of antithrombotics. Compared to patients with upper tract bleeding, patients with SGIA tend to be older.
Risk factors
Risk factors include the use of antiplatelet agents, including nonsteroidal anti-inflammatory drugs (NSAIDs) and P2Y12 receptor inhibitors (eg.clopidogrel).
Data from observational studies show an aggregate relative risk (RR) of SGIA with the use of of 1.8 (1.1-3.0). NSAIDs in general (including aspirin) have been shown to increase the risk of diverticular bleeding, a finding also evidenced with antiplatelet agents other than clopidogrel.
It is confirmed that vitamin K antagonists (VKAs) increase the risk of all-cause gastrointestinal bleeding (SGI) by three times compared to placebo, due to the probable bleeding of pre-existing gastrointestinal lesions.
Direct oral anticoagulants (ACOD) are associated with a higher risk of SGI than traditional anticoagulation; however, dabigatran and rivaroxaban have an increased risk of SGI compared to warfarin and other ACODs. However, there is no difference in SGIA risk between ACODs and conventional anticoagulants.The overall risk was similar between rivaroxaban and dabigatran compared to warfarin and, in the comparison of individual ACODs, data suggest that rivaroxaban has a higher risk of SGIA than apixaban.
Compared to antiplatelet drugs, ACODs have not been shown to increase the risk of new-onset diverticular haemorrhage. Patients who have new-onset SGIA after initiation of oral anticoagulants are more likely to receive a later diagnosis of colorectal cancer. Therefore it is important to ensure that patients have colon cancer screened before starting these medications.
Etiology of SGIA
The etiology of SGIA is heterogeneous and includes several distinct pathophysiology and course conditions. However, diverticula bleeding is the most common cause, with a frequency, according to the observed cohorts, ranging from 26.4% to 64% of cases.
Other common etiologies include: ischemic colitis, hemorrhoids, angiectasias, colorectal neoplasia, post-polypectomy bleeding, colitis (inflammatory, infectious, or radiation), NSAID-induced rectal ulcers, and radiation proctitis.
The initial assessment
anamnesis complete and physical examination to determine potential sources of bleeding and help identify patients at risk of severe bleeding and adverse outcomes such as rebleeding and mortality.
In anamesis should be taken into account: presence of cardiovascular, oncological or renal comorbidities; previous gastrointestinal surgeries; associated symptoms such as abdominal pain, altered bowel habits or unintentional weight loss.
On physical examination attention should be paid to vital signs and evaluate signs of hypovolemia. Rectal examination can help determine whether a source of bleeding may come from the anorectal region or indicate the presence of melena, which can increase the likelihood of upper bleeding. Drugs should be reviewed for the presence of NSAIDs, antiplatelets and anticoagulants.
History and results of physical examination, with a previous history of decompensated liver disease or previous peptic ulcer, along with objective findings of epigastric discomfort or visible stigmata of advanced liver disease may indicate the possibility of a source of upper bleeding in a patient with severe hematochezia.
Risk determination tools
Initial risk assessment is increasingly important to identify patients at low or high risk of requiring hospital intervention. Among the various risk stratification tools, attention was placed on the Oakland punteggio of Oakland obtainable by evaluating:
- age
- sex
- history of SGIA
- rectal exam results
- heart rate
- systolic blood pressure
- hemoglobin level.
The Oakland score was validated as a strong discriminant for safe discharge using data from a network of 140 hospitals in the United States.A score of Oakland <8 had a 98% sensitivity to safe discharge, and the extent of the score <10 maintained 96% sensitivity to safe discharge.
Based on these data, the European Society for Gastrointestinal Endoscopy and the British Society of Gastroenterology recommend that in patients with self-limiting lower bleeding and no adverse clinical features, the Oakland score ≤ 8 can be used to guide patients to outpatient evaluation.
However, before disseminating the implementation of this score, additional multicenter data on the use of Oakland score thresholds in driving early discharge will be required, and for now no score beyond that of Oakland has been widely used to predict adverse outcomes in the SGIA.
Therefore, risk prediction scores in SGIA cases should not replace clinical judgment and should be used as an additional tool in medical decision-making.
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