PTU-50 Watch and wait, a rational management for lower gastrointestinal bleeding in the elderly?

Published Date: 07th November 2021

Publication Authors: Baig D

Introduction
Many patients presenting to hospital with lower gastrointestinal bleeding (LGIB) are elderly and co-morbid. British Society of Gastroenterology (BSG) guidelines recommend LGI endoscopy for all patients admitted with LGIB. As the majority of LGIB ceases spontaneously and risks of endoscopy increase with patient age, a ‘watch and wait’ management approach may be appropriate for older patients.

Methods
Patients aged ≥75 years presenting with LGIB to seven hospital trusts from June 1st– September 1st 2019 were included. Data on presentation, management and outcomes were recorded, then compared to current BSG guidelines.

Results
127 patients were included. 47% were male with a mean age 84 (range 75-96), 73.2% of patients had ≥2 listed co-morbidities. Mean Shock Index (SI) on presentation was 0.69, with a SI >1 being rare (7.0%) and reduced to 2.4% following resuscitation. Of stable patients (SI<1), 94.3% were classified as having a major bleed (Oakland Score >8). 96.1% of presenting patients were admitted, while 3.9% were discharged from A&E. 80% of these discharged patients had an Oakland Score >8. 21 (17.2%) of admitted patients received an inpatient lower GI endoscopy; 19% of which received endoscopic therapy. The most commonly identified cause of LGIB was diverticulosis (23.8%). Overall, 82.8% of admitted patients received no inpatient lower GI endoscopy and were managed conservatively. Comparing those who underwent LGI endoscopy versus a watch and wait approach, there was no difference in inpatient mortality (0% vs 4%, p=1.0) or 30-day re-admission rate (9.5% vs 22.8%, p= 0.24). However, undergoing inpatient LGI endoscopy was associated with greater median length of stay (8 days vs 3 days, p=0.0002)

Conclusion
Age and co-morbidities complicate risk stratification in the elderly as many will score highly regardless of bleed severity, limiting the role of the Oakland Score. Endoscopic assessment of all elderly patients presenting with LGIB is not performed in real world practice, may not be necessary or even appropriate. Although not in keeping with current guidelines, this watch and wait approach does not appear to be associated with adverse outcomes in the elderly.

Davies, M; Baig, D et al. (2021). PTU-50 Watch and wait, a rational management for lower gastrointestinal bleeding in the elderly? . Gut. 70 (4), A67-A68.

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