ASGE issues a GRADE guideline on endoscopy in acute lower gastrointestinal bleeding

Its scope is the set of decisions that actually get made at two in the morning. It addresses colonoscopy versus CT with or without angiography as the first modality; urgent versus non-urgent colonoscopy; and prepped versus unprepped colonoscopy. For diverticular bleeding specifically it compares endoscopic band ligation against clipping, and direct clipping of the bleeding site or vessel against indirect closure of the diverticulum. It also covers the roles of upper endoscopy and surgery, and sets out absolute and relative contraindications to colonoscopy.

Two of those questions are worth flagging because practice is genuinely inconsistent. The urgent-versus-non-urgent question has repeatedly failed to show benefit for rushing to colonoscopy, and the prepped-versus-unprepped question determines whether a patient is scoped overnight or in the morning after preparation. A unit whose out-of-hours pathway predates this guideline should read the recommendations table and check them against local practice.

A guideline is only useful if the pathway changes, so the practical step is to compare your department's written protocol against the summary table rather than to read and forget.

• Review your unit's out-of-hours lower GI bleeding pathway against the new ASGE recommendations table
• Check specifically what your protocol says about urgent versus non-urgent colonoscopy and about unprepped colonoscopy
• Note the guideline addresses CT with or without angiography as a first modality, which is often the practical choice overnight
• For diverticular bleeding, the choice between band ligation and clipping, and between direct and indirect clipping, is now addressed with GRADE
• Remember the coverage gap: ACG, AGA, AASLD, EASL and CDSCO documents do not reach this feed