What is the workup for gastrointestinal (GI) bleed?

From the Guidelines

The workup for a gastrointestinal (GI) bleed should begin with a thorough history and physical examination, followed by laboratory tests including complete blood count, coagulation studies, and comprehensive metabolic panel, and initial resuscitation with intravenous fluids and blood products as necessary, with the most recent guidelines from the British Society of Gastroenterology 1 recommending stratification of patients as unstable or stable, and further categorization of stable bleeds as major or minor using a risk assessment tool. The initial assessment of a patient with GI bleed is crucial in determining the severity of the bleed and guiding further management.

• A thorough history and physical examination should be performed to identify potential causes of the bleed and assess the patient's hemodynamic stability.
• Laboratory tests, including complete blood count, coagulation studies, and comprehensive metabolic panel, should be ordered to evaluate the patient's blood loss and overall health status.
• Initial resuscitation with intravenous fluids and blood products may be necessary depending on the patient's hemodynamic stability, with the goal of maintaining adequate blood pressure and perfusion of vital organs. The British Society of Gastroenterology guidelines 1 provide a framework for the management of lower GI bleeding, including the use of risk assessment tools to categorize patients as having major or minor bleeds.
• Patients with minor self-terminating bleeds (such as those with an Oakland score ≤8 points) and no other indications for hospital admission can be discharged for urgent outpatient investigation 1.
• Patients with major bleeds should be admitted to hospital for colonoscopy, and those who are haemodynamically unstable or have a shock index (heart rate/systolic BP) of >1 after initial resuscitation and/or active bleeding is suspected, CT angiography provides the fastest and least invasive means to localise the site of blood loss before planning endoscopic or radiological therapy 1. The American College of Radiology guidelines 1 also provide recommendations for the radiologic management of lower GI tract bleeding, including the use of CT angiography, radionuclide scans, and transcatheter arteriography to identify the site of bleeding and guide targeted therapy.
• The choice of diagnostic modality depends on the patient's clinical presentation and hemodynamic stability, as well as the availability of expertise and resources.
• The goal of radiologic examination is to identify the site of bleeding and guide targeted therapy, with the ultimate goal of improving patient outcomes and reducing morbidity and mortality.

From the Research

Initial Assessment and Resuscitation

• The initial approach to managing a patient presenting with nonvariceal upper gastrointestinal bleeding (NVUGIB) involves resuscitation and risk stratification strategies in the Emergency Department 2.
• Hemodynamic stability is defined as a systolic blood pressure >90 mmHg, heart rate <100 beats, mean arterial pressure >65 mmHg, and no requirement for vasopressors 3.

Proton Pump Inhibitor (PPI) Treatment

• PPIs reduce gastric acid production and are used to manage upper GI bleeding 4.
• The use of PPIs prior to endoscopy in patients with upper GI bleeding may reduce the need for endoscopic haemostatic treatment at index endoscopy, but the evidence for other clinical outcomes is insufficient 4.
• A study found that movement toward preferential use of intravenous push (IVP) PPI prior to endoscopy for hemodynamically stable patients with confirmed or suspected upper GI bleeding resulted in similar rates of continued bleeding or re-bleeding and generated modest cost savings 3.

Transfusion Medicine

• Most transfusion guidelines recommend the use of restrictive blood transfusion in stable gastrointestinal bleeding 5.
• There is a lack of evidence supporting the use of platelet and fresh frozen plasma transfusion in gastrointestinal bleeding 5.

Comparison of PPI Treatments

• A study compared the treatment effects of continuous infusion and low-dose esomeprazole therapies in patients with non-variceal upper GI bleeding and found no significant difference between the two groups in terms of re-bleeding, need of surgery, and mortality 6.
• Another study found that PPI infusion therapy following endoscopic hemostasis treatment was not superior to low-dose PPI therapy in terms of re-bleeding, need of surgery, and mortality 6.