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gi.lgib.core.v1PRODUCTION
gi.lgib.core.v1

Lower GI Bleeding

gastroenterologyacuteadult
Hard-required inputs
0 / 11
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm LGIB scope; remember ~15% of apparent LGIB is brisk UGIB — keep EGD on the table (ACG 2024)

Inputs
1
Actions
0
Advance rule
Set
Advance when

lower source plausible

Patient inputs (16)

Oakland score component; CRC risk if ≥45; angiodysplasia risk if elderly (ACG 2024)

Hemodynamic instability defines massive LGIB; shock index (ACG 2024)

Tachycardia / shock index >1 → unstable (ACG 2024)

Hold/reverse decision; resume timing (ACG 2024)

Discontinue NSAIDs after diverticular bleed (ACG 2023)

Oakland score component; transfusion threshold (Hgb 7 per ACG 2023)

Coagulopathy / thrombocytopenia management (ACG 2024)

Coagulopathy reversal threshold; on-anticoagulation pathway (ACG 2024)

Renal function; contrast for CTA; medication dosing (ACG 2024)

Elevated BUN:Cr ratio → upper source likelihood (ACG 2024)

Diagnostic + therapeutic for LGIB after bowel prep (ACG 2024)

First-line for hemodynamically significant LGIB per ACG 2023

Exclude brisk upper source (~15% of apparent LGIB) (ACG 2024)

Post-polypectomy bleed pathway (up to 14d post-procedure) (ACG 2024)

Phenotype — diverticular / hemorrhoidal / IBD / radiation (ACG 2024)

Perfusion marker in massive bleed (ACG 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningperitonitis_LGIB
    Rebound, guarding, free air on imaging in LGIB context (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehemodynamic_instability_unstable_LGIB (ACG 2024)
    SBP <90 or HR >110 with ongoing hematochezia (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresuspected_brisk_UGIB
    Hematochezia with BUN:Cr >30 OR hemodynamic disproportion (massive shock with limited rectal output) (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereanticoagulation_reversal_active_bleed
    Active LGIB on warfarin (INR >1.5), DOAC, or recent thrombolysis (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererebleed_within_72h
    Hgb drop ≥2 g/dL OR recurrent hematochezia within 72h of index colonoscopy (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildoakland_le_8_outpatient (ACG 2024)
    Oakland score ≤8 with stable vitals, no syncope, reliable follow-up (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

LGIB acute regimen — resuscitation + reversal + colonoscopic/IR hemostasis (ACG 2023)
axis: lgib_acutestep 1 - Step 1 — Resuscitation and triage
Selected step "Step 1 — Resuscitation and triage" — Hematochezia or significant rectal bleeding
  • normal_saline_or_LR
    first line
    crystalloid
    500-1000 mL IV bolus titrated • IV • PRN
    triggers: hemodynamic_instability
    Initial volume restoration
    rxcui 9863
  • packed_red_blood_cells
    first line
    blood_product
    1-2 units • IV • PRN
    triggers: Hgb_<7, Hgb_<8_with_CV_disease
    Restrictive transfusion threshold per ACG 2023 / Villanueva 2013

ed playbook — drug actions (4)

  1. 1. crystalloid resuscitation (ACG 2024)
    500-1000 mL IV LR bolus (ACG 2024) • IV • PRN
    trigger: Hemodynamic instability (ACG 2024)
    Initial volume restoration (ACG 2024)
  2. 2. PRBC transfusion
    1-2 units • IV • PRN
    trigger: Hgb <7 (or <8 with CAD/ACS) (ACG 2024)
    Restrictive threshold ACG 2023
  3. 3. PEG bowel prep
    4-6 L PO/NG over 3-4h • PO/NG • one-time
    trigger: Planned colonoscopy (ACG 2024)
    Required for diagnostic + therapeutic visualisation (ACG 2024)
  4. 4. anticoag reversal
    Vit K 10 mg IV + 4F-PCC; idarucizumab; andexanet • IV • one-time
    trigger: Active bleed on anticoag (ACG 2024)
    Per drug-specific reversal (ACG 2024)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Hematochezia (bright red blood per rectum) (ACG 2024); Melena (consider brisk upper source — ~15% of apparent LGIB) (ACG 2024); Syncope / presyncope with rectal bleeding (ACG 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Lower GI Bleeding** (gi.lgib.core.v1).
Phenotype framing: Diverticular > hemorrhoidal > CRC > angiodysplasia > IBD > ischemic > post-polypectomy > radiation > brisk UGIB > anal fissure (ACG 2024)
Scope: Confirm LGIB scope; remember ~15% of apparent LGIB is brisk UGIB — keep EGD on the table (ACG 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **LGIB acute regimen — resuscitation + reversal + colonoscopic/IR hemostasis (ACG 2023)** — step "Step 1 — Resuscitation and triage".
1. normal_saline_or_LR 500-1000 mL IV bolus titrated IV PRN (crystalloid, first line) — Initial volume restoration
2. packed_red_blood_cells 1-2 units IV PRN (blood_product, first line) — Restrictive transfusion threshold per ACG 2023 / Villanueva 2013

Setting playbook (ed) — Resuscitate, exclude brisk UGIB (BUN:Cr, NGT consideration), risk-stratify with Oakland score, decide CTA-first (unstable) vs colonoscopy after prep (stable), reverse anticoagulation (ACG 2024)
3. crystalloid resuscitation (ACG 2024) 500-1000 mL IV LR bolus (ACG 2024) IV PRN — Hemodynamic instability (ACG 2024) (Initial volume restoration (ACG 2024))
4. PRBC transfusion 1-2 units IV PRN — Hgb <7 (or <8 with CAD/ACS) (ACG 2024) (Restrictive threshold ACG 2023)
5. PEG bowel prep 4-6 L PO/NG over 3-4h PO/NG one-time — Planned colonoscopy (ACG 2024) (Required for diagnostic + therapeutic visualisation (ACG 2024))
6. anticoag reversal Vit K 10 mg IV + 4F-PCC; idarucizumab; andexanet IV one-time — Active bleed on anticoag (ACG 2024) (Per drug-specific reversal (ACG 2024))

Non-pharmacologic actions:
- NPO (ACG 2024)
- Two large-bore IV access (ACG 2024)
- CTA abdomen-pelvis if hemodynamically unstable / brisk active bleed (ACG 2023 conditional recommendation)
- Colonoscopy after prep within 24h of admission (does not need to be emergent) (ACG 2024)
- IR / surgical consult on standby (ACG 2024)

AVOID / contraindication checks:
- Tranexamic_acid_avoid_in_GI_bleed_HALT_IT (ACG 2024)
- NSAID_discontinue_after_diverticular_bleed (ACG 2024)
- Antiplatelet_aspirin_continue_for_secondary_CV (ACG 2024)
- DOAC_resumption_after_hemostasis_within_7d_when_safe (ACG 2024)

Monitoring

Regimen monitoring:
- serial Hgb q6 8h first 24h (ACG 2024)
- lactate clearance q6h if shock (ACG 2024)
- INR post reversal (ACG 2024)
- rebleed surveillance 48 72h (ACG 2024)
- stool output color frequency (ACG 2024)

Setting (ed) monitoring:
- SpO2 + telemetry (ACG 2024)
- Serial Hgb q6h (ACG 2024)
- Vitals q1h until stable (ACG 2024)
- Lactate clearance q6h if shock (ACG 2024)
- Hourly UOP (ACG 2024)

Follow-up plan: 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)
- Close-out criterion: follow-up scheduled and counseled

Monitoring phase: Serial Hgb q6-8h, vitals, stool output color/frequency, UOP, INR after reversal, rebleed surveillance 48-72h, lactate clearance if shock (ACG 2024)

Disposition

Current setting: ed — Resuscitate, exclude brisk UGIB (BUN:Cr, NGT consideration), risk-stratify with Oakland score, decide CTA-first (unstable) vs colonoscopy after prep (stable), reverse anticoagulation (ACG 2024)

Disposition criteria:
- Discharge: Oakland ≤8, no syncope, reliable follow-up, outpatient colonoscopy within 7d (ACG 2024)
- Admit ward: Oakland >8, stable vitals (ACG 2024)
- Admit ICU: hemodynamic instability, massive transfusion, ongoing brisk bleed (ACG 2024)

Escalation triggers (move to higher acuity):
- Persistent SBP <90 despite resuscitation → CTA + IR embolization (ACG 2024)
- Massive ongoing hematochezia → emergent CTA / surgery (ACG 2024)
- Suspected UGIB source (BUN:Cr >30, melena, hemodynamic disproportion) → EGD first (ACG 2024)
- Peritonitis → emergent surgery (ACG 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Rebound, guarding, free air on imaging in LGIB context (ACG 2024)
- [SEVERE] SBP <90 or HR >110 with ongoing hematochezia (ACG 2024)
- [SEVERE] Hematochezia with BUN:Cr >30 OR hemodynamic disproportion (massive shock with limited rectal output) (ACG 2024)

Citations

- ACG 2023 LGIB Guideline (Strate & Gralnek) + ESGE 2021 LGIB + BSG 2019 LGIB (Oakland score derivation) + Villanueva 2013 restrictive transfusion (NEJM) [PMID:26925883](https://pubmed.ncbi.nlm.nih.gov/26925883/)
- Cited evidence (PMID 28651935) [PMID:28651935](https://pubmed.ncbi.nlm.nih.gov/28651935/)
- Cited evidence (PMID 23281973) [PMID:23281973](https://pubmed.ncbi.nlm.nih.gov/23281973/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ACG 2023 LGIB Guideline (Strate & Gralnek) + ESGE 2021 LGIB + BSG 2019 LGIB (Oakland score derivation) + Villanueva 2013 restrictive transfusion (NEJM) — PMID:26925883
  • Cited evidence (PMID 28651935) — PMID:28651935
  • Cited evidence (PMID 23281973) — PMID:23281973