Synopsis
Stabilise acute haematochezia, recognise diverticular haemorrhage as a diagnosis requiring localisation and exclusion of alternatives, and coordinate endoscopic, radiological and antithrombotic decisions safely.
- Diverticular bleeding is often abrupt, painless and substantial because a vasa recta adjacent to a diverticulum ruptures; many episodes stop spontaneously but recurrence is important.
- Do not call bleeding diverticular simply because diverticula were seen previously. Cancer, angiodysplasia, ischaemic colitis, inflammatory disease, haemorrhoids and an upper-GI source need proportionate exclusion.
- Judge physiology before estimating colour or volume: calculate shock index, repeat observations, assess perfusion and establish venous access while history is taken.
Key red flags
Abrupt painless passage of red or maroon blood, often with clots, in an older adult with diverticulosis is characteristic, but source attribution remains provisional until localisation or exclusion is adequate.
Investigation priorities
Classify haemodynamic instability and response to resuscitation before selecting the diagnostic route.
Management branches
Haematochezia accompanies shock, ongoing major loss or failure to respond durably to initial resuscitation.
- Begin ABCDE, two suitable venous lines, urgent bloods and crossmatch, warming, continuous observations and the local major-haemorrhage protocol when activation criteria are met.
- Call senior gastroenterology and colorectal teams, alert interventional radiology and transfusion services, and document last antithrombotic doses while analgesia and resuscitation continue.
Bleeding is clinically major but haemodynamic stability is sustained after initial assessment.
Key medicines
Red-cell transfusionUse the current NICE restrictive threshold and target for clinically significant bleeding, individualised during exsanguination or active myocardial ischaemia under the major-haemorrhage protocol.
Anticoagulant reversalUse the agent-specific current hospital protocol only for life-threatening or uncontrolled bleeding after identifying the anticoagulant, last dose, renal function and indication.