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## Complete Summary

#### GUIDELINE TITLE

ASGE guideline: the role of endoscopy in the patient with lower-GI
bleeding.

#### BIBLIOGRAPHIC SOURCE(S)

Davila RE, Rajan E, Adler DG, Egan J, Hirota WK, Leighton JA, Qureshi W,
Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, Baron TH, Faigel DO. ASGE
Guideline: the role of endoscopy in the patient with lower-GI bleeding.
Gastrointest Endosc 2005 Nov;62(5):656-60. \[58 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16246674)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Lower gastrointestinal (GI) bleeding caused by:

-   Diverticular disease

-   Ischemic colitis

-   Vascular ectasia

-   Hemorrhoids

-   Neoplasia

-   Postpolypectomy

-   Nonsteroidal anti-inflammatory drug (NSAID)-induced colopathy

-   Other miscellaneous etiologies

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Gastroenterology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To describe the role of gastrointestinal (GI) endoscopy in patients with
lower GI bleeding

#### TARGET POPULATION

Patients with suspected lower gastrointestinal bleeding

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Colonoscopy (and preparation of the colon using polyethylene
    glycol-based solutions)

2.  Air-contrast barium enema

3.  Virtual colonoscopy

4.  Computed tomographic (CT) colonography

5.  Upper endoscopy

6.  Digital rectal examination

7.  Sigmoidoscopy

8.  Anoscopy

9.  Nasogastric (NG) tube placement

10. Gastric lavage

11. Radiologic evaluation

    -   Radioactive-labeled red-blood-cell scanning

    -   Angiography

**Management**

1.  Thermal contact modalities, including heat probe and
    bipolar/multipolar coagulation

2.  Epinephrine injection

3.  Endoscopic metallic-clip placement

4.  Superselective arterial embolization with various agents (gelatin
    sponge, microcoils, polyvinyl alcohol particles, and balloons)

5.  Surgery

6.  Cessation and avoidance of aspirin and non-steroidal
    anti-inflammatory drugs (NSAIDs)

#### MAJOR OUTCOMES CONSIDERED

-   Specificity and sensitivity of diagnostic tests

-   Mortality rate

-   Hospitalization rate and length of stay

-   Control of hemorrhage

-   Bleeding recurrence rate

-   Complications associate with interventions

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A MEDLINE literature search was performed, and additional references
were obtained from the bibliographies of the identified articles and
from the recommendations of expert consultants. When little or no data
existed from well-designed prospective trials, emphasis was given to
results from large series and reports from recognized experts.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### 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

Review\
Review of Published Meta-Analyses

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Guidelines for appropriate utilization of endoscopy are based on a
critical review of the available data and expert consensus.

#### 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

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Recommendations are followed by evidence grades **(A-C)** identifying
the type of supporting evidence. Definitions of the evidence grades are
presented at the end of the \"Major Recommendations\" field.

**[Evaluation and Management]{.underline}**

**Occult Fecal Blood**

Patients with chronic lower gastrointestinal bleeding (LGIB) that
presents with occult fecal blood should undergo colonoscopy. If
colonoscopy cannot be completed to the cecum, air-contrast barium enema
should be obtained to evaluate the portions of the colon not visualized
endoscopically. Virtual colonoscopy or computed tomographic (CT)
colonography also can be used to rule out a proximal colonic lesion in
patients who have had an incomplete colonoscopy.

Upper endoscopy should be considered if a source is not identified on
colonoscopy, particularly if there are upper-gastrointestinal (GI)
symptoms or anemia.

**Melena**

The diagnostic evaluation of a patient with melena should begin with
upper endoscopy, because an upper-tract source is most likely in this
setting. If an upper-GI source is not identified, then colonoscopy
should be pursued. Obscure GI bleeding is defined as bleeding of unknown
origin that persists or recurs after an initial negative endoscopic
evaluation, including upper endoscopy and colonoscopy. The evaluation
and the management of obscure GI bleeding are discussed in another
guideline.

**Intermittent Scant Hematochezia**

Chronic intermittent passage of small amounts of visible red blood is
the most common pattern of LGIB. Because most patients with scant
hematochezia have an anorectal or a distal colonic source of bleeding,
the initial evaluation in young, healthy patients ([\<]{.underline}40
years of age) should be a digital rectal examination and sigmoidoscopy,
with or without anoscopy. Young, otherwise healthy patients with a
convincing, benign source of bleeding on sigmoidoscopy, such as
hemorrhoids or anal fissures, generally do not need to undergo
colonoscopy for further evaluation. Patients over 50 years of age; those
with anemia; those with significant risk factors for colorectal
neoplasia; and/or those with worrisome symptoms, such as weight loss or
change in bowel habits, should undergo colonoscopy. Please see the
American Society for Gastrointestinal Endoscopy practice guidelines on
the endoscopic therapy of anorectal disorders for the management of
anorectal sources of hematochezia, including radiation proctopathy,
internal hemorrhoids, and anal fissures.

**Severe Acute Bleeding**

Patients with severe LGIB should undergo clinical evaluation and
stabilization as is done with upper-GI bleeding.

Nasogastric (NG)-tube placement should be strongly considered,
especially in the setting of hemodynamic compromise. A clear NG-tube
aspirate does not rule out an upper-GI source, whereas the presence of
bile makes an upper source unlikely. A positive aspirate should prompt
emergent upper endoscopy. In patients with a previous history of peptic
ulcer disease, a recent history of nonsteroidal anti-inflammatory drug
(NSAID) use, significant upper-GI symptoms, or a nondiagnostic NG
lavage, upper endoscopy should be performed either before or after
colonoscopy. Upper endoscopy also should be performed after colonoscopy
in cases where a colonic source is not identified.

Colonoscopy is recommended in the early evaluation of LGIB. The
procedure should be performed after preparation of the colon by using
polyethylene glycol-based solutions. The preparation can be administered
per NG tube or orally at a rate of approximately 1 L every 30 to 45
minutes. The colonic preparation facilitates endoscopic visualization,
improves diagnostic yield, and may improve the safety of the procedure
by decreasing the risk of perforation.

Several endoscopic treatment modalities can be used to achieve
hemostasis when a source of LGIB is identified at the time of
colonoscopy. The identification of a visible vessel or a pigmented
protuberance within a diverticular segment is rare and may denote those
patients at high risk for persistent or recurrent diverticular bleeding.
Thermal contact modalities, including heat probe and bipolar/multipolar
coagulation, and epinephrine injection can be used independently or
together in the treatment of bleeding colonic diverticula.

Endoscopic metallic-clip placement also serves as an alternative
treatment for diverticular hemorrhage. Angiographic or surgical therapy
may be necessary in cases of massive bleeding from a diverticulum that
may not be amenable to endoscopic therapy.

Endoscopic therapy for vascular ectasia is widely accepted and is highly
successful. Both thermal and injection methods can be used effectively.
Successful cauterization rates of 87% have been described when using
thermal therapy. Lower power settings than those used for bleeding
gastroduodenal ulcers are recommended because of the increased risk of
perforation in the right colon. Radiologic evaluation of patients with
acute LGIB includes radioactive-labeled red-blood-cell scanning and
angiography. Tagged-red-blood-cell scanning is positive in 45% of
patients and has an overall accuracy of 78% for localizing the site of
bleeding. Intestinal bleeding rates as low as 0.1 mL/min can be detected
with this technique. Because angiography requires faster rates of
bleeding for the identification of a bleeding source (rate of 1 mL/min),
tagged-red-blood-cell scanning may be used by angiographers as a
screening study to identify those patients with active ongoing bleeding
who may benefit from angiotherapy.

Superselective arterial embolization with various agents (gelatin
sponge, microcoils, polyvinyl alcohol particles, and balloons) has now
replaced intra-arterial vasopressin for the treatment of LGIB. Control
of bleeding can be achieved in 44% to 91% of cases and is associated
with fewer major complications compared with vasopressin infusion.
Potential complications of this technique include abdominal pain, fever,
intestinal ischemia, and intestinal strictures. The rate of recurrent
bleeding with superselective embolization ranges from 7% to 33%.
Patients who fail angiographic therapy with ongoing or recurrent LGIB
usually require surgery.

Surgery should be considered in patients with significant, ongoing
hematochezia that requires the transfusion of more than 6 units of
packed red blood cells in a 24-hour period or if bleeding recurs.
Preoperative localization of lower-GI bleeding is crucial to avoiding
extensive surgical intervention (\"blind colectomy\") and in ensuring
that the bleeding is truly arising from the lower GI tract. Directed
segmental resection is possible when the bleeding site is identified
before surgery, as with an adenocarcinoma of the colon, or in a patient
with diverticular disease limited to the left colon.

**[Summary]{.underline}**

-   LGIB is defined as bleeding emanating from a source distal to the
    ligament of Treitz and may present in multiple ways, including
    occult fecal blood, iron deficiency anemia, melena, intermittent
    scant hematochezia, or acute bleeding. **(C)**

-   Colonoscopy is effective in the diagnosis and the treatment of LGIB.
    **(A)**

-   NG-tube placement and/or upper endoscopy to look for an upper-GI
    source of bleeding should be considered if a source is not
    identified on colonoscopy, particularly if there is a history of
    upper-GI symptoms or anemia. **(A)**

-   Colonoscopy is recommended in the early evaluation of severe acute
    LGIB. **(A)**

-   Thermal contact modalities, including heat probe and
    bipolar/multipolar coagulation, and/or epinephrine injection can be
    used in the treatment of bleeding diverticula, vascular ectasia, or
    postpolypectomy bleeding sites. **(A)**

-   Angiography and/or tagged-red-blood-cell scanning can be used in the
    setting of active, persistent bleeding or in cases of nondiagnostic
    endoscopic evaluation. **(A)**

-   Preoperative localization of bleeding should be attempted in all
    patients before surgical intervention. **(C)**

-   Aspirin and NSAIDs can be associated with lower-GI bleeding. If
    possible, these agents should be stopped and/or avoided in patients
    with a history of lower-GI bleeding. **(C)**

**[Definitions]{.underline}**:

A.  Prospective controlled trials

B.  Observational studies

C.  Expert opinion

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and classified for the
recommendations using the following scheme:

A.  Prospective controlled trials

B.  Observational studies

C.  Expert opinion

When little or no data exist from well-designed prospective trials,
emphasis is given to results from large series and reports from
recognized experts. Guidelines for appropriate utilization of endoscopy
are based on a critical review of the available data and expert
consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate use of endoscopy in the diagnosis and management of patients
with lower gastrointestinal (GI) bleeding, providing bleeding control,
avoidance of complications, and prevention of recurrence

#### POTENTIAL HARMS

Superselective arterial embolization with various agents (gelatin
sponge, microcoils, polyvinyl alcohol particles, and balloons) may be
associated with potential complications including abdominal pain, fever,
intestinal ischemia, and intestinal strictures.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Further controlled clinical studies are needed to clarify aspects of
this statement, and revision may be necessary as new data appear.
Clinical consideration may justify a course of action at variance to
these recommendations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Davila RE, Rajan E, Adler DG, Egan J, Hirota WK, Leighton JA, Qureshi W,
Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, Baron TH, Faigel DO. ASGE
Guideline: the role of endoscopy in the patient with lower-GI bleeding.
Gastrointest Endosc 2005 Nov;62(5):656-60. \[58 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16246674)

#### ADAPTATION

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

#### DATE RELEASED

2005 Nov

#### GUIDELINE DEVELOPER(S)

American Society for Gastrointestinal Endoscopy - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society for Gastrointestinal Endoscopy

#### GUIDELINE COMMITTEE

Standards of Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Douglas O. Faigel, MD (*Chair*); Todd H. Baron, MD
(*Vice Chair*); Raquel E. Davila, MD; Elizabeth Rajan, MD; Douglas G.
Adler, MD; James Egan, MD; William K. Hirota, MD; Jonathan A. Leighton,
MD; Waqar Qureshi, MD; Marc J. Zuckerman, MD; Robert Fanelli, MD (*SAGES
Representative*); Jo Wheeler-Harbaugh RN (*SGNA Representative*)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Society for Gastrointestinal Endoscopy (ASGE) Web
site](http://www.asge.org/PublicationsProductsIndex.aspx?id=352).

Print copies: Available from the American Society for Gastrointestinal
Endoscopy, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on December 7, 2005. The
information was verified by the guideline developer on December 14,
2005.

#### COPYRIGHT STATEMENT

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

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008