What is the management of Gastrointestinal (GI) bleeding?

From the Guidelines

Management of gastrointestinal (GI) bleeding requires prompt assessment and intervention based on the severity and location of bleeding, with an emphasis on stabilizing the patient and identifying the source of bleeding, as approximately 75% of episodes of acute lower GI bleeding due to diverticulosis stop spontaneously 1. Initially, stabilize the patient by establishing large-bore IV access (two 18G or larger), administering crystalloid fluids, and monitoring vital signs.

• For severe bleeding, transfuse packed red blood cells to maintain hemoglobin above 7 g/dL (or 9 g/dL in patients with cardiovascular disease)
• Correct coagulopathy with fresh frozen plasma, platelets, or prothrombin complex concentrate as needed. For upper GI bleeding, administer high-dose proton pump inhibitors (e.g., pantoprazole 80mg IV bolus followed by 8mg/hr infusion for 72 hours).
• Octreotide (50-100mcg IV bolus followed by 25-50mcg/hr infusion) is beneficial for suspected variceal bleeding. Endoscopy should be performed within 24 hours, or urgently in unstable patients, to identify and treat the bleeding source.
• For lower GI bleeding, colonoscopy after bowel preparation is the diagnostic procedure of choice, as supported by recent advances in the evaluation and management of acute lower gastrointestinal bleeding 2. Angiography with embolization or surgery may be necessary for persistent bleeding not controlled by endoscopic measures.
• Rectal bleeding with hemodynamic instability requires immediate surgical consultation, highlighting the importance of prompt assessment and intervention in managing GI bleeding 1. The underlying cause of bleeding determines subsequent management, including continued acid suppression for peptic ulcers, beta-blockers for varices, or removal of offending medications like NSAIDs or anticoagulants when appropriate. Key considerations in managing GI bleeding include:
• Stabilizing the patient and identifying the source of bleeding
• Correcting coagulopathy and transfusing packed red blood cells as needed
• Using endoscopy and colonoscopy to diagnose and treat the bleeding source
• Considering angiography with embolization or surgery for persistent bleeding
• Removing offending medications and providing ongoing management based on the underlying cause of bleeding, as emphasized in the most recent study on the radiologic management of lower gastrointestinal tract bleeding 1.

From the Research

Initial Assessment and Resuscitation

• The initial assessment of a patient with gastrointestinal bleeding focuses on bleeding activity, severity, and hemodynamic compromise 3.
• Fluid resuscitation is essential to reverse hypovolemia, and blood transfusions may be necessary to replenish lost blood 3, 4.
• A restrictive transfusion threshold of 7-8 g/dL is recommended 5, while others suggest a threshold of 70-80 g/L 4.

Pharmacologic Interventions

• Proton pump inhibitors (PPIs) are the main pharmacologic intervention for upper gastrointestinal bleeding, aiming to stabilize mucosal blood clots and promote hemostasis 3, 6, 5.
• Antibiotics and vasoactive drugs are recommended for patients with cirrhosis 4, and vasopressors should be administered urgently if variceal hemorrhage is suspected 5.

Endoscopic Intervention

• Endoscopy should be performed within 24 hours of presentation, with earlier endoscopy considered for high-risk patients 4, 5.
• Endoscopic treatment is used for variceal bleeding (e.g., ligation for esophageal varices and tissue glue for gastric varices) and high-risk non-variceal bleeding (e.g., injection, thermal probes, or clips) 4, 5.
• High-dose PPIs are recommended after endoscopy for patients with non-variceal bleeding, while those with variceal bleeding should continue taking antibiotics and vasoactive drugs 4.

Management of Recurrent Bleeding

• Recurrent ulcer bleeding is treated with repeat endoscopic therapy, and subsequent bleeding is managed by interventional radiology or surgery 4, 5.
• Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt placement 4, 5.

Multidisciplinary Collaboration

• The management of severe upper gastrointestinal bleeding requires multidisciplinary collaboration, prompt recognition and resuscitation, careful use of blood products, early correction of coagulopathy, and early endoscopic or radiologic interventions 6.