External validation of the NOBLADS score, a risk scoring system for severe acute lower gastrointestinal bleeding

Oakland score to identify low-risk patients with lower gastrointestinal bleeding performs well among emergency department patients

BACKGROUND

The Oakland Score predicts risk of 30-day adverse events among hospitalized patients with lower gastrointestinal bleeding (LGIB) possibly identifying patients who may be safe for discharge. The Oakland Score has not been studied among emergency department (ED) patients with LGIB. The Oakland Score composite outcome includes re-bleeding, defined as additional blood transfusion requirements and/or a further decrease in hematocrit (Hct) >/= 20% after 24 h in clinical stability; red blood cell transfusion; therapeutic intervention to control bleeding, including surgery, mesenteric embolization, or endoscopic hemostasis; in-hospital death, all cause; and re-admission with further LGIB within 28 days. Prediction variables include age, sex, previous LGIB admission, systolic blood pressure, heart rate, and hemoglobin concentration, and scores range from 0 to 35 points, with higher scores indicating greater risk.

METHODS

Retrospective cohort study of adult (≥ 18 years old) patients with a primary ED diagnosis of LGIB across 21 EDs from March 1st, 2018, through March 1st, 2020. We excluded patients who were more likely to have upper gastrointestinal bleeding (esophago-gastroduodenoscopy without LGIB evaluation), patients who left against medical advice or prior to ED provider evaluation, ED patients without active health plan membership, and patients with incomplete Oakland Score variables. We assessed predictive accuracy by reporting the area under the receiver operator curve (AUROC) and sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios at multiple clinically relevant thresholds.

RESULTS

We identified 8,283 patients with LGIB, 52% were female, mean age was 68, 49% were non-White, and 27% had an adverse event. The AUROC for predicting an adverse event was 0.85 (95% CI 0.84-0.86). There were 1,358 patients with an Oakland Score of

CONCLUSION

The Oakland Score had high predictive accuracy among ED patients with LGIB. Prospective evaluation is needed to understand if the risk score could augment ED decision-making and improve outcomes and resource utilization.

Collapse

Key Words

• Emergency medicine
• Lower gastrointestinal bleeding
• Risk stratification

Collapse

MESH Headings Collapse

Grants

• Kaiser Permanente Northern California Community Health

Collapse

Affiliation(s)

Daniel D DiLena Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA.
Sean C Bouvet Department of Emergency Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
Madeline J Somers Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA
Maqdooda A Merchant Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA
Theodore R Levin Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA Department of Gastroenterology, Kaiser Permanente Antioch Medical Center, Antioch, CA, USA
Adina S Rauchwerger Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA
Dana R Sax Division of Research, Kaiser Permanente Northern California, 4480 Hacienda Dr, Pleasanton, CA, 94588, USA Department of Emergency Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA

Collapse

Collaborators Collapse

Emergency medicine updates: Lower gastrointestinal bleeding

INTRODUCTION

Lower gastrointestinal bleeding (LGIB) is a condition commonly seen in the emergency department. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease.

OBJECTIVE

This paper evaluates key evidence-based updates concerning LGIB for the emergency clinician.

DISCUSSION

LGIB is most commonly due to diverticulosis or anorectal disease, though there are a variety of etiologies. The majority of cases resolve spontaneously, but patients can have severe bleeding resulting in hemodynamic instability. Initial evaluation should focus on patient hemodynamics, the severity of bleeding, and differentiating upper gastrointestinal bleeding from LGIB. Factors associated with LGIB include prior history of LGIB, age over 50 years, and presence of blood clots per rectum. Computed tomography angiography is the imaging modality of choice in those with severe bleeding to diagnose the source of bleeding and guide management when embolization is indicated. Among stable patients without severe bleeding, colonoscopy is the recommended modality for diagnosis and management. A transfusion threshold of 7 g/dL hemoglobin is recommended based on recent data and guidelines (8 g/dL in those with myocardial ischemia), though patients with severe bleeding and hemodynamic instability should undergo emergent transfusion. Anticoagulation reversal may be necessary. If bleeding does not resolve, embolization or endoscopic therapies are necessary. There are several risk scores that can predict the risk of adverse outcomes; however, these scores should not replace clinical judgment in determining patient disposition.

CONCLUSIONS

An understanding of literature updates can improve the care of patients with LGIB.

LONG-HOSP Score: A Novel Predictive Score for Length of Hospital Stay in Acute Lower Gastrointestinal Bleeding - A Multicenter Nationwide Study

INTRODUCTION

Length of stay (LOS) in hospital affects cost, patient quality of life, and hospital management; however, existing gastrointestinal bleeding models applicable at hospital admission have not focused on LOS. We aimed to construct a predictive model for LOS in acute lower gastrointestinal bleeding (ALGIB).

METHODS

We retrospectively analyzed the records of 8,547 patients emergently hospitalized for ALGIB at 49 hospitals (the CODE BLUE-J Study). A predictive model for prolonged hospital stay was developed using the baseline characteristics of 7,107 patients and externally validated in 1,440 patients. Furthermore, a multivariate analysis assessed the impact of additional variables during hospitalization on LOS.

RESULTS

Focusing on baseline characteristics, a predictive model for prolonged hospital stay was developed, the LONG-HOSP score, which consisted of low body mass index, laboratory data, old age, nondrinker status, nonsteroidal anti-inflammatory drug use, facility with ≥800 beds, heart rate, oral antithrombotic agent use, symptoms, systolic blood pressure, performance status, and past medical history. The score showed relatively high performance in predicting prolonged hospital stay and high hospitalization costs (area under the curve: 0.70 and 0.73 for derivation, respectively, and 0.66 and 0.71 for external validation, respectively). Next, we focused on in-hospital management. Diagnosis of colitis or colorectal cancer, rebleeding, and the need for blood transfusion, interventional radiology, and surgery prolonged LOS, regardless of the LONG-HOSP score. By contrast, early colonoscopy and endoscopic treatment shortened LOS.

CONCLUSIONS

At hospital admission for ALGIB, our novel predictive model stratified patients by their risk of prolonged hospital stay. During hospitalization, early colonoscopy and endoscopic treatment shortened LOS.

Outcomes and performance of risk scores in acute lower gastrointestinal bleeding

Background and Aim

Treatment of acute lower gastrointestinal bleeding (LGIB) remains problematic, and clinical data is limited compared to that of upper GIB. This study aimed to describe the clinical outcomes and predictors of rebleeding and validate the performance of proposed scoring systems in patients with acute overt LGIB.

Methods

Patients with LGIB who underwent colonoscopies between 2013 and 2018 were retrospectively reviewed. Overt LGIB patients who presented within 72 h after bleeding onset were included. Demographics, comorbidities, initial management, endoscopic finding, and treatment outcomes were collected. Factors associated with rebleeding were explored, and the performance of Oakland, NOBLAD, and Strate scores regarding mortality and rebleeding were validated.

Results

A total of 537 patients from 3402 (age 72 years, 63-80) were included. Of this, 53% took antithrombotic agents and 59% required red cell transfusion, with a median of 4 red cell units. The most common diagnoses were diverticular bleeding (31.3%) and colorectal polyp/cancer (28.9%). The median time to colonoscopy was 2.3 days, and 80.3% of patients did not receive any hemostatic intervention. The 30-day mortality and rebleeding were 2.6% and 18.3%, respectively. Patients with radiation proctitis, angioectasia, diverticulosis and using dual antiplatelet drugs were associated with recurrent bleeding. The risk scores showed low performance in predicting recurrent bleeding and mortality.

Conclusion

Acute, overt LGIB was common among elders with comorbidities. The rebleeding risk was mostly linked to underlying lesions and the use of antiplatelet drugs. The performance of current risk stratification scores remains unsatisfactory and requires further development.

Differences between patients with inpatient-onset and outpatient-onset acute lower gastrointestinal bleeding: An observational study

BACKGROUND AND AIM

The clinical severity and course of acute lower gastrointestinal bleeding (ALGIB) are believed to differ between inpatient-onset and outpatient-onset cases, but no reports have investigated these issues in detail. We aimed to evaluate the clinical differences between inpatient-onset and outpatient-onset ALGIB.

METHODS

Medical records of patients who had undergone emergency colonoscopy for ALGIB were retrospectively reviewed. The severity was evaluated using the NOBLADS score. Patients with obvious ALGIB relapse and/or persistent iron-deficiency anemia after emergency colonoscopy were considered to exhibit a poor clinical course.

RESULTS

We reviewed 723 patients with ALGIB and divided them into the inpatient-onset cohort (172 patients) and outpatient-onset cohort (551 patients). Compared with the outpatient-onset cohort, the inpatient-onset cohort had a significantly higher proportion of patients with a poor clinical course (51.2% vs 21.6%; P < 0.001) and a significantly higher mean NOBLADS score (3.6 ± 1.1 vs 2.5 ± 1.0; P < 0.001). The most common bleeding source was acute hemorrhagic rectal ulcer (52.3%) in the inpatient-onset cohort and colonic diverticular bleeding (29.4%) in the outpatient-onset cohort. Multivariate analysis showed that a platelet count < 15 × 104 /μL and albumin concentration < 3 g/dL were significantly associated with a poor clinical course in the inpatient-onset cohort.

CONCLUSIONS

The clinical course was significantly worse in the inpatient-onset cohort than in the outpatient-onset cohort. The bleeding source, clinical characteristics, and clinical course differed between the inpatient-onset and outpatient-onset cohorts. The clinical course in the inpatient-onset cohort may depend on the patient's condition at ALGIB onset.

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.

Comparison of Risk Scores for Lower Gastrointestinal Bleeding: A Systematic Review and Meta-analysis

IMPORTANCE

Clinical prediction models, or risk scores, can be used to risk stratify patients with lower gastrointestinal bleeding (LGIB), although the most discriminative score is unknown.

OBJECTIVE

To identify all LGIB risk scores available and compare their prognostic performance.

DATA SOURCES

A systematic search of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1990, through August 31, 2021, was conducted. Non-English-language articles were excluded.

STUDY SELECTION

Observational and interventional studies deriving or validating an LGIB risk score for the prediction of a clinical outcome were included. Studies including patients younger than 16 years or limited to a specific patient population or a specific cause of bleeding were excluded. Two investigators independently screened the studies, and disagreements were resolved by consensus.

DATA EXTRACTION AND SYNTHESIS

Data were abstracted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline independently by 2 investigators and pooled using random-effects models.

MAIN OUTCOMES AND MEASURES

Summary diagnostic performance measures (sensitivity, specificity, and area under the receiver operating characteristic curve [AUROC]) determined a priori were calculated for each risk score and outcome combination.

RESULTS

A total of 3268 citations were identified, of which 9 studies encompassing 12 independent cohorts and 4 risk scores (Oakland, Strate, NOBLADS [nonsteroidal anti-inflammatory drug use, no diarrhea, no abdominal tenderness, blood pressure ≤100 mm Hg, antiplatelet drug use (nonaspirin), albumin <3.0 g/dL, disease score ≥2 (according to the Charlson Comorbidity Index), and syncope], and BLEED [ongoing bleeding, low systolic blood pressure, elevated prothrombin time, erratic mental status, and unstable comorbid disease]) were included in the meta-analysis. For the prediction of safe discharge, the AUROC for the Oakland score was 0.86 (95% CI, 0.82-0.88). For major bleeding, the AUROC was 0.93 (95% CI, 0.90-0.95) for the Oakland score, 0.73 (95% CI, 0.69-0.77) for the Strate score, 0.58 (95% CI, 0.53-0.62) for the NOBLADS score, and 0.65 (95% CI, 0.61-0.69) for the BLEED score. For transfusion, the AUROC was 0.99 (95% CI, 0.98-1.00) for the Oakland score and 0.88 (95% CI, 0.85-0.90) for the NOBLADS score. For hemostasis, the AUROC was 0.36 (95% CI, 0.32-0.40) for the Oakland score, 0.82 (95% CI, 0.79-0.85) for the Strate score, and 0.24 (95% CI, 0.20-0.28) for the NOBLADS score.

CONCLUSIONS AND RELEVANCE

The Oakland score was the most discriminative LGIB risk score for predicting safe discharge, major bleeding, and need for transfusion, whereas the Strate score was best for predicting need for hemostasis. This study suggests that these scores can be used to predict outcomes from LGIB and guide clinical care accordingly.

Validation and modification of existing mortality prediction models for lower gastrointestinal bleeding: a retrospective study

Background

Lower gastrointestinal bleeding (LGIB) often subsides without medical intervention; however, in some cases, the bleeding does not stop and the patient’s condition worsens. Therefore, predicting severe LGIB in advance can aid treatment. This study aimed to evaluate variables related to mortality from LGIB and propose a scoring system.

Methods

In this retrospective study, we reviewed the medical records of patients who visited the emergency room with hematochezia between January 2016 and December 2020. Through regression analysis of comorbidities, medications, vital signs, laboratory investigations, and duration of hospital stay, variables related to LGIB-related mortality were evaluated. A scoring system was developed and the appropriateness with an area under the receiver operating characteristics curve (AUROC) was evaluated and compared with other existing models.

Results

A total of 932 patients were hospitalized for LGIB. Variables associated with LGIB-related mortality were the presence of cancer, heart rate > 100 beats/min, blood urea nitrogen level ≥ 30 mg/dL, an international normalized ratio > 1.50, and albumin level ≤ 3.0 g/dL. The AUROCs of the models CNUH-4 and CNUH-5 were 0.890 (p < 0.001; cutoff, 2.5; 95% confidence interval, 0.0851–0.929) and 0.901 (p < 0.001; cutoff, 3.5; 95% confidence interval, 0.869–0.933), respectively.

Conclusions

The model developed for predicting the risk of LGIB-related mortality is simple and easy to apply clinically. The AUROC of the model was better than that of the existing models.

Acute Lower Gastrointestinal Bleeding in an Emergency Department and Performance of the SHA2PE Score: A Retrospective Observational Study

Lower gastrointestinal bleeding (LGIB) is a frequent cause of emergency department (ED) consultation, leading to investigations but rarely to urgent therapeutic interventions. The SHA₂PE score aims to predict the risk of hospital-based intervention, but has never been externally validated. The aim of our single-center retrospective study was to describe patients consulting our ED for LGIB and to test the validity of the SHA₂PE score. We included 251 adult patients who consulted in 2017 for hematochezia of <24 h duration; 53% were male, and the median age was 54 years. The most frequent cause of LGIB was unknown (38%), followed by diverticular disease and hemorrhoids (14%); 20% had an intervention. Compared with the no-intervention group, the intervention group was 26.5 years older, had more frequent bleeding in the ED (47% vs. 8%) and more frequent hypotension (8.2% vs. 1.1%), more often received antiplatelet drugs (43% vs. 18%) and anticoagulation therapy (28% vs. 9.5%), more often had a hemoglobin level of <10.5 g/dl (49% vs. 6.2%) on admission, and had greater in-hospital mortality (8.2% vs. 0.5%) (all p < 0.05). The interventions included transfusion (65%), endoscopic hemostasis (47%), embolization (8.2%), and surgery (4%). The SHA₂PE score predicted an intervention with sensitivity of 71% (95% confidence interval: 66–83%), specificity of 81% (74–86%), and positive and negative predictive values of 53% (40–65%) and 90% (84–95%), respectively. SHA₂PE performance was inferior to that in the original study, with a 1 in 10 chance of erroneously discharging a patient for outpatient intervention. Larger prospective validation studies are needed before the SHA₂PE score can be recommended to guide LGIB patient management in the ED.

Development and Validation of a Scoring System to Predict Severe Acute Lower Gastrointestinal Bleeding in Vietnamese

BACKGROUND/AIMS

The prevalence of acute lower gastrointestinal bleeding (ALGIB) has progressively increased worldwide but there are few studies in Asian populations. This study aimed to develop and validate a scoring system to predict severe ALGIB in Vietnamese.

METHODS

Risk factors for severe ALGIB were identified by multiple logistic regression analysis using data from a retrospective cohort of 357 patients admitted to a tertiary hospital. These factors were weighted to develop the severe acute lower gastrointestinal bleeding (SALGIB) score to predict severe ALGIB. The performance of SALGIB was validated in a prospective cohort of 324 patients admitted to 6 other hospitals using area under the receiver operating characteristics curve (AUC) analysis.

RESULTS

There were four factors at admission independently associated with severe ALGIB in the derivation cohort: heart rate ≥ 100/min, systolic blood pressure < 100 mmHg, hematocrit < 35%, and platelets ≤ 150 × 103/µL. The SALGIB score determined severe ALGIB with AUC values of 0.91 and 0.86 in the derivation and validation cohorts, respectively. A SALGIB score < 2 associated with low risk of severe ALGIB in both cohorts (3.7% and 1.2%; respectively).

CONCLUSIONS

The SALGIB score has good performance in discriminating risk of severe ALGIB in Vietnamese.

Overt gastrointestinal bleeding following haploidentical haematopoietic stem cell transplantation: incidence, outcomes and predictive models

Gastrointestinal bleeding (GIB) accounts for a significant proportion of life-threatening bleeding cases occurring after allogeneic haematopoietic stem cell transplantation (allo-HSCT). However, data on GIB after haploidentical HSCT (haplo-HSCT) are not available. A total of 3180 patients received haplo-HSCT at Peking University People's Hospital from January 2015 to November 2019, and GIB occurred in 188 of these patients (incidence of 5.9%). Platelet counts <30 × 10⁹/L, viral hepatitis, acute kidney injury (AKI), gastrointestinal disease or bleeding before HSCT and sinusoidal obstruction syndrome (SOS) were determined to be significant risk factors for the occurrence of GIB after haplo-HSCT. Grade III-IV acute graft-versus-host disease (aGVHD), AKI, thrombotic microangiopathy (TMA), disseminated intravascular coagulation (DIC) and gastrointestinal disease or bleeding before HSCT were significantly related to mortality in patients with GIB after haplo-HSCT. The predictive models developed for the occurrence and mortality of GIB performed well in terms of discrimination, and they might assist clinicians with personalised strategies for GIB prevention and treatment in patients after haplo-HSCT.

Differences in emergency endoscopy outcomes according to gastrointestinal bleeding location

BACKGROUND AND AIM

With recent technological advances in the field of endoscopic hemostasis, the prognosis of patients with gastrointestinal (GI) bleeding has improved. However, few studies have reported on the clinical course of patients with GI bleeding. This study aimed to evaluate the differences in clinical outcomes of patients with lower GI bleeding (LGIB) compared with upper GI bleeding (UGIB) and the factors related to their prognosis.

METHODS

Patients who had undergone emergency endoscopy for GI bleeding were retrospectively reviewed. The severity of GI bleeding was evaluated using the Glasgow-Blatchford (GB), AIMS65, and NOBLADS scores. Patients in whom obvious GI bleeding relapsed and/or iron deficiency anemia persisted after emergency endoscopy were considered to exhibit rebleeding.

RESULTS

We reviewed 1697 consecutive patients and divided them into UGIB (1054 patients) and LGIB (643 patients) groups. The proportion of patients with rebleeding was significantly greater in the UGIB group than in the LGIB group; the mortality rate was significantly higher in the UGIB group than in the LGIB group. Multivariate analysis showed that a GB score ≥12 and an AIMS65 score ≥2 were significantly associated with rebleeding in the UGIB group, whereas a NOBLADS score ≥4 was significantly associated with rebleeding in the LGIB group. Notably, the influence of emergency endoscopy differed according to GI bleeding location.

CONCLUSIONS

The clinical course was significantly worse in patients with UGIB than in patients with LGIB. The influence of emergency endoscopy differed according to GI bleeding location.

Explainable Machine Learning Model for Predicting GI Bleed Mortality in the Intensive Care Unit

INTRODUCTION

Acute gastrointestinal (GI) bleed is a common reason for hospitalization with 2%-10% risk of mortality. In this study, we developed a machine learning (ML) model to calculate the risk of mortality in intensive care unit patients admitted for GI bleed and compared it with APACHE IVa risk score. We used explainable ML methods to provide insight into the model's prediction and outcome.

METHODS

We analyzed the patient data in the Electronic Intensive Care Unit Collaborative Research Database and extracted data for 5,691 patients (mean age = 67.4 years; 61% men) admitted with GI bleed. The data were used in training a ML model to identify patients who died in the intensive care unit. We compared the predictive performance of the ML model with the APACHE IVa risk score. Performance was measured by area under receiver operating characteristic curve (AUC) analysis. This study also used explainable ML methods to provide insights into the model's outcome or prediction using the SHAP (SHapley Additive exPlanations) method.

RESULTS

The ML model performed better than the APACHE IVa risk score in correctly classifying the low-risk patients. The ML model had a specificity of 27% (95% confidence interval [CI]: 25-36) at a sensitivity of 100% compared with the APACHE IVa score, which had a specificity of 4% (95% CI: 3-31) at a sensitivity of 100%. The model identified patients who died with an AUC of 0.85 (95% CI: 0.80-0.90) in the internal validation set, whereas the APACHE IVa clinical scoring systems identified patients who died with AUC values of 0.80 (95% CI: 0.73-0.86) with P value <0.001.

DISCUSSION

We developed a ML model that predicts the mortality in patients with GI bleed with a greater accuracy than the current scoring system. By making the ML model explainable, clinicians would be able to better understand the reasoning behind the outcome.

Risk stratification in upper and upper and lower GI bleeding: Which scores should we use?

Risk assessment is widely used in upper gastrointestinal bleeding (UGIB) however no score accurately predicts all important clinical outcomes. This review discusses the performance of the Rockall score, pre-endsocopy Rockall score, Glasgow-Blatchford score, AIMS-65 and newer scores such as Progetto Nazionale Emorragia Digestiva and CANUKA scores. The quality of external validation varies considerably for each score. There is a relative lack of risk scores available for use in lower GI bleeding (LGIB) but recent developments have focussed on the identification of low risk patients. The BLEED, NOBLADS, Strate and Sengupta scores have been developed to predict severe bleeding or death, each with varying performance. The Oakland score has been developed to identify patients at low risk of adverse outcomes who may be suitable for outpatient management. The comparative performance of the LGIB scores and Rockall, Glasgow-Blatchford and AIMS-65 in the prediction of outcomes in LGIB is also discussed.

Initial management for acute lower gastrointestinal bleeding

Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospital admission. Patients with LGIB often experience persistent or recurrent bleeding and require blood transfusions and interventions, such as colonoscopic, radiological, and surgical treatments. Appropriate decision-making is needed to initially manage acute LGIB, including emergency hospitalization, timing of colonoscopy, and medication use. In this literature review, we summarize the evidence for initial management of acute LGIB. Assessing various clinical factors, including comorbidities, medication use, presenting symptoms, vital signs, and laboratory data is useful for risk stratification of severe LGIB, and for discriminating upper gastrointestinal bleeding. Early timing of colonoscopy had the possibility of improving identification of the bleeding source, and the rate of endoscopic intervention, compared with elective colonoscopy. Contrast-enhanced computed tomography before colonoscopy may help identify stigmata of recent hemorrhage on colonoscopy, particularly in patients who can be examined immediately after the last hematochezia. How to deal with nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents after hemostasis should be carefully considered because of the risk of rebleeding and thromboembolic events. In general, aspirin as primary prophylaxis for cardiovascular events and NSAIDs were suggested to be discontinued after LGIB. Managing acute LGIB based on this information would improve clinical outcomes. Further investigations are needed to distinguish patients with LGIB who require early colonoscopy and hemostatic intervention.