In this in-depth episode of Hospital Medicine Unplugged, we tackle the evidence-based inpatient management of lower gastrointestinal bleeding (LGIB)—from first contact in the ED to secondary prevention at discharge.

We start with stabilization and triage: ABCs, two large-bore IVs, targeted labs, and a restrictive transfusion strategy—generally transfuse at Hb <7 g/dL (aim >7), or >9 g/dL if significant cardiovascular disease or ongoing instability. We cover how to separate brisk UGIB from true LGIB, when an NG lavage helps, and how to use (but not overtrust) tools like the Oakland score alongside clinical judgment and ICU criteria.

Diagnostics and timing—what actually changes outcomes: for stable patients, colonoscopy after adequate prep remains first-line for diagnosis and therapy, but routine “urgent” colonoscopy hasn’t shown better mortality, rebleeding, or LOS. In the unstable or unprepped patient, CT angiography leads for localization and can hand off directly to IR embolization. We map a clean pathway for when to escalate to surgery.

Therapeutics by etiology:
• Diverticular bleeding—clips or band ligation; how we choose and why.
• Angiodysplasia—argon plasma coagulation, with notes on recurrence and when octreotide enters the chat.
• Post-polypectomy bleeding—injection, thermal, clips.
• Ischemic colitis/IBD flares—supportive care or anti-inflammatory escalation rather than hemostasis.

Medications that matter (and those that don’t): PPIs have no role in LGIB; tranexamic acid (HALT-IT) offers no benefit and potential harm. We give a practical, risk-balanced approach to antithrombotics: when to reverse, when aspirin should stop (primary) or continue (secondary), and why most anticoagulated patients should restart within ~7 days once safe.

We close with system moves that improve care—multidisciplinary pathways, 24/7 colonoscopy/CTA/IR access, and standardized algorithms that shorten time-to-diagnosis and reduce resource waste.

Concise, guideline-driven, practical medicine—no fluff, just the evidence for safer, more effective inpatient management of LGIB.