From the Guidelines
For a patient with a GI bleed who is hemodynamically stable and has a low Oakland score, outpatient management is appropriate. This approach is supported by the British Society of Gastroenterology guidelines, which suggest that patients with a minor self-terminating bleed (such as those with an Oakland score ≤8 points) and no other indications for hospital admission can be discharged for urgent outpatient investigation 1. The guidelines also recommend that patients with a low Oakland score can be managed as outpatients, as they are at low risk of adverse outcomes and rebleeding.
When managing a patient with a GI bleed as an outpatient, it is essential to begin with close observation and supportive care, including intravenous fluid resuscitation if needed to maintain hemodynamic stability. Discontinue medications that may worsen bleeding, such as NSAIDs, anticoagulants, and antiplatelet agents, if possible. Administer a proton pump inhibitor (PPI) such as pantoprazole 40 mg IV or orally twice daily for 3-5 days, then transition to once daily for 2-4 weeks, as recommended by the guidelines 1. Monitor hemoglobin levels and vital signs regularly, and schedule follow-up within 1-2 weeks. Provide clear instructions on when to return, such as worsening symptoms, hematemesis, melena, dizziness, or syncope.
The patient should also undergo diagnostic evaluation with upper endoscopy within 24 hours if upper GI bleeding is suspected, or colonoscopy within 24-48 hours for suspected lower GI bleeding to identify and potentially treat the bleeding source 1. This approach balances patient safety with resource utilization by avoiding unnecessary hospitalization for low-risk patients. According to a cost-effectiveness analysis, this approach can also be cost-effective, as it reduces the need for supportive treatments, such as RBC transfusion, and reduces the length of stay 1.
Key considerations in outpatient management include:
- Close observation and supportive care
- Discontinuation of medications that may worsen bleeding
- Administration of a PPI
- Monitoring of hemoglobin levels and vital signs
- Diagnostic evaluation with upper endoscopy or colonoscopy
- Clear instructions on when to return for follow-up care.
From the Research
Treatment for GI Bleed
Hemodynamically Stable and Low Oakland Score
- For patients with acute lower gastrointestinal bleeding who are hemodynamically stable and have a low Oakland score (≤ 8 points), the European Society of Gastrointestinal Endoscopy (ESGE) recommends discharge for outpatient investigation 2.
- The ESGE also recommends a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion, and a post-transfusion target hemoglobin concentration of 7-9 g/dL 2.
- In patients with a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy is recommended, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion, and a post-transfusion target hemoglobin concentration of ≥ 10 g/dL 2.
- The use of proton pump inhibitors (PPIs) or histamine 2-receptor antagonists (H2RAs) may be considered to reduce the risk of peptic ulcer bleeding, especially in patients with a history of peptic ulcer or Helicobacter pylori infection 3, 4.
- However, there is no direct evidence to support the use of PPIs or H2RAs in the treatment of GI bleed with a low Oakland score, and the decision to use these medications should be based on individual patient factors and clinical judgment.
Management of Anticoagulant and Antiplatelet Therapy
- The ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk 2.
- Direct oral anticoagulants should be temporarily withheld at presentation in patients with major lower gastrointestinal bleeding 2.
- Aspirin should not be withheld in patients taking low-dose aspirin for secondary cardiovascular prevention, and should be resumed within 5 days or earlier if hemostasis is achieved or there is no further evidence of bleeding 2.
- Dual antiplatelet therapy (low-dose aspirin and a P2Y12 receptor antagonist) should not be routinely discontinued before cardiology consultation, and the decision to continue or interrupt therapy should be based on individual patient factors and clinical judgment 2.