Clinical Commander

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gi.lgib.core.v1

Lower GI Bleeding

gastroenterologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is full and current (ACG 2023 + ESGE 2021 + BSG 2019 + Villanueva 2013 + Green 2005 + Strate 2003) with 10 phenotypes (diverticular, hemorrhoidal, CRC, angiodysplasia, IBD, ischemic, post-polypectomy, radiation proctitis, massive, on-anticoag) and full medication/dosing tables. Problem-package at assessment-of-lower-gastrointestinal-bleeding/ with full atom set; design brief lives at sibling gi.gi_bleed.acute/_design-brief.md (shared with UGIB). Workup `lgib` is registered in clinical-tools-registry. Oakland score is referenced as manual interpretation rule (calc_oakland not yet in BUILTIN_CALCULATORS — calc.has_bled, calc.map, calc.news2 wired instead). Gaps for PRODUCTION: evidence.pmids array empty (manifest cites guideline labels but no numeric PMIDs); no engine-specific test_files; no regimen_axes (PRBC, IV crystalloid, PPI empiric, vitamin K, 4-factor PCC, idarucizumab, andexanet alfa wired in manifest.medications without RxCUI verification). Calculator gap: Oakland score not yet implemented as a BUILTIN_CALCULATOR — add for full INTEGRATED→PRODUCTION promotion.

Entry points (4)

  • symptom
    Hematochezia (bright red blood per rectum) (ACG 2024)
    hematochezia
  • symptom
    Melena (consider brisk upper source — ~15% of apparent LGIB) (ACG 2024)
    melena_with_lower_source
  • symptom
    Syncope / presyncope with rectal bleeding (ACG 2024)
    syncope_with_blood_loss
  • lab_abnormality
    Acute drop in hemoglobin (ACG 2024)
    acute_drop_in_hgb

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Oakland score component; CRC risk if ≥45; angiodysplasia risk if elderly (ACG 2024)
  • sbprequired
    vital • used at CONTEXT
    Hemodynamic instability defines massive LGIB; shock index (ACG 2024)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia / shock index >1 → unstable (ACG 2024)
  • hemoglobinrequired
    lab • used at INITIAL_WORKUP
    Oakland score component; transfusion threshold (Hgb 7 per ACG 2023)
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    Coagulopathy / thrombocytopenia management (ACG 2024)
  • inrrequired
    lab • used at INITIAL_WORKUP
    Coagulopathy reversal threshold; on-anticoagulation pathway (ACG 2024)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Renal function; contrast for CTA; medication dosing (ACG 2024)
  • bun_creatinine_ratiorequired
    lab • used at INITIAL_WORKUP
    Elevated BUN:Cr ratio → upper source likelihood (ACG 2024)
  • lactate
    lab • used at RED_FLAGS
    Perfusion marker in massive bleed (ACG 2024)
  • cta_abdomen_pelvis
    imaging • used at BRANCHING_WORKUP
    First-line for hemodynamically significant LGIB per ACG 2023
  • colonoscopyrequired
    imaging • used at INITIAL_WORKUP
    Diagnostic + therapeutic for LGIB after bowel prep (ACG 2024)
  • egd_exclude_upper_source
    imaging • used at BRANCHING_WORKUP
    Exclude brisk upper source (~15% of apparent LGIB) (ACG 2024)
  • anticoag_antiplateletrequired
    history • used at CONTEXT
    Hold/reverse decision; resume timing (ACG 2024)
  • nsaid_userequired
    history • used at CONTEXT
    Discontinue NSAIDs after diverticular bleed (ACG 2023)
  • recent_polypectomy
    history • used at CONTEXT
    Post-polypectomy bleed pathway (up to 14d post-procedure) (ACG 2024)
  • known_diverticulosis_hemorrhoids_ibd
    history • used at CONTEXT
    Phenotype — diverticular / hemorrhoidal / IBD / radiation (ACG 2024)

12-phase flow (12)

  1. 1FRAME
    Confirm LGIB scope; remember ~15% of apparent LGIB is brisk UGIB — keep EGD on the table (ACG 2024)
    inputs: age
    advance: lower source plausible
  2. 2ENTRY
    Recognize hematochezia, syncope with blood loss, or acute Hgb drop (ACG 2024)
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, anticoag/antiplatelet/NSAID review, recent polypectomy, IBD history, prior GI bleeds, family CRC (ACG 2024)
    inputs: sbp, hr, anticoag_antiplatelet, nsaid_use, recent_polypectomy, known_diverticulosis_hemorrhoids_ibd
    advance: context captured
  4. 4RED_FLAGS
    Hemodynamic instability, massive hematochezia, syncope, ongoing active bleed, supratherapeutic anticoagulation, suspected upper source, peritoneal signs, Hgb <7, severe coagulopathy (ACG 2024)
    inputs: sbp, hr, hemoglobin, lactate
    advance: unstable patient routed or stabilized
  5. 5INITIAL_WORKUP
    CBC, type and crossmatch, BMP, INR/aPTT, BUN:Cr ratio, lactate if severe; bowel prep; colonoscopy (ACG 2024)
    inputs: hemoglobin, platelets, inr, creatinine, bun_creatinine_ratio, colonoscopy
    actions: panel.cbc, panel.renal, lgib
    advance: baseline labs + endoscopy plan
  6. 6BRANCHING_WORKUP
    CTA first if hemodynamically unstable (ACG 2023); EGD to exclude upper source; tagged RBC scan / capsule endoscopy if obscure
    inputs: cta_abdomen_pelvis, egd_exclude_upper_source
    advance: phenotype identified (diverticular / hemorrhoidal / CRC / angiodysplasia / IBD / ischemic / post-polypectomy / radiation / massive / on-anticoag)
  7. 7DIFFERENTIAL
    Diverticular > hemorrhoidal > CRC > angiodysplasia > IBD > ischemic > post-polypectomy > radiation > brisk UGIB > anal fissure (ACG 2024)
    advance: etiology identified
  8. 8RISK_STRATIFICATION
    Oakland score (≤8 → safe outpatient discharge per ACG 2023); shock index; NEWS2; HAS-BLED for anticoag
    inputs: hemoglobin, sbp, hr
    actions: calc.has_bled, calc.news2, calc.map
    advance: risk score documented
  9. 9TREATMENT
    IV crystalloid, restrictive transfusion (Hgb 7; 8-9 if CAD/ACS), endoscopic hemostasis (clip/cautery/injection), CTA-guided embolization for massive, hold NSAIDs, continue aspirin for secondary CV prevention, discontinue NSAID after diverticular bleed (ACG 2024)
    inputs: hemoglobin, inr
    advance: hemostasis achieved or escalated
  10. 10DISPOSITION
    ICU for hemodynamic instability / massive transfusion; floor for stable LGIB; safe discharge if Oakland ≤ 8 (ACG 2024)
    inputs: sbp, hemoglobin
    advance: destination set
  11. 11MONITORING
    Serial Hgb q6-8h, vitals, stool output color/frequency, UOP, INR after reversal, rebleed surveillance 48-72h, lactate clearance if shock (ACG 2024)
    inputs: hemoglobin
    advance: stable for 24h or escalated
  12. 12FOLLOWUP
    Discharge if Oakland ≤8; outpatient colonoscopy within 7d if not done; GI follow-up 2-4 weeks; anticoag resumption with cardiology; iron repletion; recurrence counseling (ACG 2024)
    advance: follow-up scheduled and counseled