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Guideline Summary
Guideline Title
Management of acute lower gastrointestinal (GI) bleeding.
Bibliographic Source(s)
University of Pennsylvania Health System (UPHS). Management of acute lower GI bleeding. Philadelphia (PA): University of Pennsylvania Health System (UPHS); 2009 Jan. 6 p.
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Acute lower gastrointestinal (GI) bleeding

Note: The scope of this guideline excludes bleeding from upper GI causes such as peptic ulcers. It also excludes subacute or chronic bleeding.

Guideline Category
Evaluation
Management
Clinical Specialty
Colon and Rectal Surgery
Emergency Medicine
Gastroenterology
Nuclear Medicine
Radiology
Intended Users
Physicians
Guideline Objective(s)

  • To apply evidence-based practice principles to the management of patients with acute lower gastrointestinal (GI) bleeding
  • To apply clinical evidence to selection of a nuclear imaging modality for diagnosing and localizing lower GI bleeding

Target Population

Patients in the University of Pennsylvania Health System with acute lower gastrointestinal bleeding

Interventions and Practices Considered

Evaluation

  1. Bowel prep and colonoscopy
  2. Computed tomography arteriogram
  3. 99mTechnetium-labeled red blood cell scan

Note: 99mTechnetium-sulfur colloid scan was considered but not recommended.

Management

  1. Timing of evaluations
  2. Sequencing of evaluation methods
  3. Referral to interventional radiology for embolization of the bleeding source
  4. Treatment planning
Major Outcomes Considered

  • Sensitivity and specificity of evaluation methods for location of acute lower gastrointestinal tract bleeding
  • Time required to localize site of bleeding
  • Proportion of cases requiring more than one evaluation method
  • Sequelae from evaluation methods

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

 The following sites were searched:

  • Medline
  • Cochrane Library
  • AHRQ Evidence-Based Practice Series
  • University Health Systems Consortium
  • Health Technology Assessment (HTA) databases

Study inclusion/exclusion criteria included:

  • Patients with acute lower gastrointestinal bleeding, stable enough for imaging procedures, and without an obvious source of bleeding such as recent colon surgery
  • Technetium 99m-labeled red blood cell scan, technetium 99m sulfur colloid scan, computed tomography (CT) angiography intervention
  • Other imaging procedures including mesenteric arteriography and colonoscopy
  • Outcomes that included diagnosis and localization of the bleeding source, time required to localize bleeding
Number of Source Documents

20

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

To apply evidence-based decision-making to this clinical question, Center for Evidence-based Practice (CEP) completed an evidence review, and then convened a committee meeting with representatives from all the clinical specialties involved. Committee members read the CEP evidence report prior to the meeting.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The Centers for Evidence-Based Practice (CEP) committee discussed the advantages and disadvantages of each test used to diagnose the cause and source of acute lower GI bleeding. Additional discussion among committee members and other physicians took place at Medical Grand Rounds on November 11.

The committee reviewed the evidence and arrived at consensus on the guidelines. CEP prepared an algorithm based on the recommendations from the meeting and the subsequent comments of task force members.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

The algorithm and report were discussed and approved by the task force.

Recommendations

Major Recommendations

Based on the evidence report, the availability of particular tests at Hospital of the University of Pennsylvania (HUP) and clinical experience, the committee developed an algorithm for management of patients with acute lower gastrointestinal (GI) bleeding (see figure 1 in the original guideline document). The members of the committee unanimously agreed that if a patient with acute lower GI bleeding is a suitable candidate for colonoscopy, then colonoscopy should be the first test. The gastroenterologist should be consulted first, to assess the patient's suitability for colonoscopy.  Since colonoscopy requires a minimum of six hours bowel preparation in order to be safe and effective (without preparation, the view through the endoscope will be obscured by feces and blood, reducing the ability of the procedure to locate the bleeding site while increasing the risk of perforation and other side effects), this path (through box 7 in the algorithm in the original guideline document) only applies to the patients whose bleeding is not so acute and can safely wait at least six hours before treatment.

Computed tomography (CT) should be the next test used if the patient is not a suitable candidate for colonoscopy, or if colonoscopy fails to diagnose the cause and site of bleeding (box 6 in the guideline algorithm). This is because CT is available at all hours without advance preparation.  If CT is positive, and localizes the bleeding site, the patient should be referred to interventional radiology for embolization of the bleeding source.

If CT fails to localize the bleeding site and the bleeding is continuing (box 9 in the guideline algorithm), the patient should be referred for a nuclear imaging procedure using 99mTc-labeled red blood cells. The committee agrees unanimously that this test should be used rather than the 99mTc-sulfur colloid scan (Alavi scan). The committee recommends that while the patient is being prepared for colonoscopy, the nuclear medicine department should be notified of the case, so they can be prepared in case an RBC scan is called for.

For patients whose bleeding is so severe that definitive therapy is required in two hours or less (box 5 in the guideline algorithm), the only available test is CT. Once CT results are available, positive or negative, the interventional radiology and emergency surgery attending physicians should work together to determine the appropriate treatment for the patient.

Clinical Algorithm(s)

An algorithm "Hospital of the University of Pennsylvania Guideline for Management of Acute Lower GI Bleeding" and comments pertaining to steps in the algorithm are provided.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting each recommendation was not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate evaluation and management of patients with acute lower gastrointestinal bleeding

Potential Harms

Not stated

Contraindications

Contraindications

Colonoscopy and/or the necessary bowel preparation may be contraindicated for some patients.

Implementation of the Guideline

Description of Implementation Strategy

Implementation and Audit

During the guideline development process, some of the task force members noted that computed tomography (CT) scanning and other diagnostic procedures were not always completed within the expected time. The committee believes that the solution for this problem is to improve communications, and specifically recommended that the physician managing the case call the CT resident on call to advise him or her of the urgency of the case. It was also recommended that the resident be advised to alert the radiology attending on call of the pending case.

Another area where improved communication was recommended by the task force is in planning treatment. In particular, the emergency surgery and interventional radiology attendings should consult with each other when deciding on treatment in urgent and emergent cases.  Because so many different departments are involved in the diagnosis and treatment of acute gastrointestinal bleeding, and the consequences of failing to diagnose and treat these bleeds in a timely manner can be dire, the clinical algorithm includes specific advice on who to contact when. The guideline developers all agree that consulting with their departments when in doubt about how to proceed is not an imposition on their staff, and consulting earlier is preferable to consulting later.

Implementation Tools
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
University of Pennsylvania Health System (UPHS). Management of acute lower GI bleeding. Philadelphia (PA): University of Pennsylvania Health System (UPHS); 2009 Jan. 6 p.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Jan
Guideline Developer(s)
University of Pennsylvania Health System - Academic Institution
Source(s) of Funding

University of Pennsylvania Health System

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

The Guideline Panel Members: Benjamin Braslow, MD (Emergency Surgery); Chaitanya Divgi, MD  (Nuclear Medicine); David Jaffe, MD (Gastroenterology); Nick Papanicolaou, MD (CT); Jose Pascual, MD, PhD (Emergency Surgery); Scott Trerotola, MD (Interventional Radiology)

Financial Disclosures/Conflicts of Interest

All participants were asked to disclose any financial or other conflicts of interest relevant to the topic at hand.  No relevant conflicts were identified.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) by request. Please contact Katie.thomas@uphs.upenn.edu.

Availability of Companion Documents

The following is available:

  • A systematic review on nuclear and CT imaging for patients with lower GI bleeding. Philadelphia (PA): University of Pennsylvania Health System (UPHS); 2009. 15 p.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on November 25, 2009. The information was verified by the guideline developer on December 10, 2009.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

©Copyright 2009 by the Trustees of the University of Pennsylvania. All rights reserved. No part of this publication may be reproduced without permission in writing from the Trustees of the University of Pennsylvania.

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