Management of Lower Gastrointestinal Bleeding (ACG guidelines 2024)


Management of Lower Gastrointestinal Bleeding: A Review of the American College of Gastroenterology’s Latest Guidelines

Lower gastrointestinal bleeding (LGIB) is a significant clinical challenge that contributes to considerable morbidity and healthcare utilization, accounting for about 20% of all gastrointestinal hemorrhage cases that necessitate hospital admission. The American College of Gastroenterology (ACG) has recently updated its clinical guidelines to incorporate new diagnostic and management strategies based on the latest evidence. This article provides an overview of these guidelines, highlighting key recommendations and their implications for practice.

Clinical Guidelines Overview

Lower Gastrointestinal Bleeding: Risk Stratification and Management

The ACG suggests the use of risk stratification tools, such as the Oakland score, to aid clinicians in identifying low-risk patients who may be suitable for early discharge and outpatient follow-up. This score, which assesses factors like age, heart rate, blood pressure, and hemoglobin levels, helps predict the likelihood of adverse outcomes, although its application is based on relatively low-quality evidence.

What is the Oakland Score?

The Oakland score is a clinical tool used to stratify risk in patients presenting with lower gastrointestinal bleeding (LGIB). It helps clinicians decide which patients are at low risk of serious outcomes and may be suitable for early discharge and outpatient management. Here’s a detailed look at how the Oakland score is calculated and its implications in clinical practice:

Components of the Oakland Score

The Oakland score comprises several clinical parameters and observations, each contributing to a cumulative score that predicts the patient’s risk of adverse outcomes such as rebleeding, need for blood transfusion, therapeutic intervention, or hospital readmission. The components include:

  1. Age: Older age is associated with higher risk.
  2. Sex: May influence the risk profile.
  3. Previous LGIB admission: Indicates potential recurrent issues.
  4. Heart rate: High heart rate can indicate more severe bleeding.
  5. Systolic blood pressure: Lower pressures may indicate significant blood loss.
  6. Digital rectal examination findings of blood: Presence of blood on examination.
  7. Hemoglobin level: Lower levels suggest more severe bleeding.

Each factor is assigned a score, and the sum gives the Oakland score, which typically ranges from 0 to 35.

Interpreting the Oakland Score

  • Low Score (0-8): Suggests a low risk of adverse outcomes. Patients with a score in this range might be candidates for early discharge and outpatient follow-up.
  • High Score (>8): Indicates a higher risk of complications, necessitating more intensive observation or intervention.

Clinical Use of the Oakland Score

The Oakland score is used primarily to guide decisions regarding the management of patients with LGIB. It can help determine which patients are unlikely to benefit from in-hospital surveillance or intensive care, thus optimizing resource use and reducing healthcare costs without compromising patient safety.

Evidence and Validation of the Oakland Score

The Oakland score is based on data collected from multiple hospitals and has been validated in various settings. However, it is important to note that while the Oakland score is a useful tool, it is not infallible. It should be used in conjunction with clinical judgment and other diagnostic information. The evidence supporting the use of the Oakland score is considered low-quality, and there are calls for more prospective, multicenter studies to further validate its efficacy and accuracy.

Limitations of the Oakland Score

Like any clinical scoring system, the Oakland score has limitations. The sensitivity and specificity can vary depending on the population and the healthcare setting. Additionally, some components, such as the findings from digital rectal examinations, may not always be available or reliably reported, which can affect the score’s accuracy.

In summary, the Oakland score is a practical tool in the management of LGIB, aiding clinicians in making informed decisions about patient care. However, it should be used as part of a broader clinical assessment.

Lower Gastrointestinal Bleeding: Diagnostic Approaches

For patients presenting with hemodynamic instability and hematochezia, the guidelines recommend computed tomography angiography (CTA) as the initial diagnostic tool. This recommendation is geared toward quickly identifying the bleeding source and facilitating rapid intervention, reflecting a shift from traditional colonoscopy to a more dynamic imaging-based approach in acute settings.

Lower Gastrointestinal Bleeding: Therapeutic Interventions

Following a positive CTA, immediate referral to interventional radiology for transcatheter arteriography is advised, potentially accompanied by embolization. This approach is strongly supported by moderate-quality evidence and is recommended over initial colonoscopy in hemodynamically unstable patients. Additionally, for those with life-threatening bleeding associated with anticoagulants, reversal is suggested, particularly when initial resuscitative measures fail.

Lower Gastrointestinal Bleeding: Post-Resolution Management

After the cessation of bleeding, the guidelines strongly advocate for the resumption of anticoagulation within seven days to mitigate the risk of thromboembolic events, supported by moderate-quality evidence. The decision to resume anticoagulation must be balanced with the individual patient’s risk of recurrent bleeding.

Lower Gastrointestinal Bleeding: Repeat Colonoscopy

For patients who have had a recent, high-quality colonoscopy showing only diverticulosis and no signs of colorectal neoplasia, repeat inpatient colonoscopy may not be necessary if bleeding subsides and there are no new symptoms. This conditional recommendation is intended to reduce unnecessary procedures and associated risks.

Lower Gastrointestinal Bleeding: Evidence and Methodology

The ACG’s guidelines are grounded in the GRADE methodology, a systematic approach to grading the strength of evidence and recommendations. Despite some recommendations being based on lower quality evidence, the inclusion of systematic literature reviews and preference for randomized trials ensures a robust evidence base.

Lower Gastrointestinal Bleeding: Implications for Practice

These guidelines mark a significant shift towards more nuanced and evidence-based approaches to managing LGIB. They emphasize the importance of individualized patient assessment and the integration of advanced imaging techniques in the diagnostic process. The use of risk scores and selective application of diagnostic and therapeutic interventions can potentially lead to more efficient use of resources and better patient outcomes.

Future Directions

The ACG acknowledges the need for further research to validate risk stratification tools like the Oakland score and to explore the efficacy and safety of anticoagulant reversal agents in the context of LGIB. Prospective studies are essential to refine these guidelines and ensure they continue to meet the evolving needs of clinical practice.


The ACG’s updated guidelines for the management of LGIB provide a comprehensive framework aimed at improving patient outcomes through evidence-based practices. As new evidence emerges, these guidelines will undoubtedly evolve, continuing to inform and enhance the care of patients experiencing this challenging clinical condition.


  1. Imran H, Alexander JT, Jackson CD. Lower Gastrointestinal Hemorrhage. JAMA 2024 Apr 24.
Last update: 27 April 2024, 08:23


Gastroenterologist - Hepatologist, Thessaloniki

PhD at Medical School, Aristotle University of Thessaloniki, Greece

PGDip at Universitair Medisch Centrum Utrecht, The Netherlands

Ex President, Hellenic H. pylori & Microbiota Study Group