On the Bleeding Edge: Mastering GI Emergencies and Inpatient GI Consultation (Live and Virtual)| September 2026-Levine

Levine_Lower GI Hemostasis

Pdf Summary

This lecture reviews current management of lower GI bleeding (LGIB), emphasizing that most cases are not fatal and are often managed without prolonged hospitalization. Overall mortality is low, but rises sharply in older, comorbid, coagulopathic, or heavily transfused patients. Common causes include diverticular bleeding, post-polypectomy bleeding, angioectasia, ischemic colitis, malignancy, and hemorrhoidal or anorectal sources.<br /><br />For diagnosis, colonoscopy has a high ability to identify the bleeding source but a relatively low therapeutic yield. Current guidance supports colonoscopy for most patients, but urgent colonoscopy within 24 hours has not been shown to improve major outcomes such as rebleeding or mortality. If bleeding has stopped and a recent high-quality colonoscopy showed diverticulosis without neoplasia, inpatient colonoscopy may not be necessary.<br /><br />For diverticular hemorrhage, endoscopic hemostasis depends on the bleeding stigma and location. Options include through-the-scope clips, endoscopic band ligation, over-the-scope clips, and, in selected cases, epinephrine injection or bipolar cautery. Direct clipping appears better than indirect “zipper” clipping for early rebleeding, while band ligation may reduce rebleeding compared with clipping but may carry a higher risk of adverse events. Newer tools such as OTSC and hemostatic powders are also discussed.<br /><br />CT angiography (CTA) is particularly useful in hemodynamically unstable patients or those with ongoing brisk bleeding. A positive CTA can guide rapid angiography and embolization, which is most effective when performed soon after imaging.<br /><br />The lecture also covers post-polypectomy bleeding, especially delayed bleeding after large right-sided hot snare EMR. Many cases do not require intervention, but repeat colonoscopy is appropriate with ongoing bleeding or instability. When treatment is needed, clipping is favored; extensive thermal therapy should be avoided.<br /><br />Key takeaways: use CTA in unstable LGIB, colonoscopy remains important for diagnosis, urgent colonoscopy rarely improves outcomes, and endoscopic clipping is central for diverticular and post-polypectomy bleeding.

Keywords

lower GI bleeding

colonoscopy

diverticular hemorrhage

CT angiography

post-polypectomy bleeding

endoscopic hemostasis

hemodynamic instability

diverticular bleeding

angiography embolization

endoscopic clipping