From the Guidelines
Patients presenting with a possible gastrointestinal (GI) bleed should be stratified as unstable or stable, with unstable patients defined as having a shock index >1, and managed accordingly with prompt hemodynamic stabilization and investigation. The management of GI bleed involves a step-wise approach, starting with risk stratification using tools such as the Oakland score for lower GI bleeds, as recommended by the British Society of Gastroenterology 1.
Key Recommendations
- Stable patients with minor self-terminating bleeds (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, while those who are haemodynamically unstable or have a shock index of >1 after initial resuscitation should undergo CT angiography to localize the site of blood loss before planning endoscopic or radiological therapy 1.
- Upper endoscopy should be performed immediately if no source is identified by initial CT angiography in patients with haemodynamic instability, as it may indicate an upper GI bleeding source 1.
- Catheter angiography with a view to embolization should be performed as soon as possible after a positive CTA to maximize chances of success, particularly in centers with a 24/7 interventional radiology service 1.
- Restrictive red blood cell (RBC) transfusion thresholds should be used in clinically stable patients who may need RBC transfusion, with a hemoglobin trigger of 70 g/L and a target of 70–90 g/L after transfusion, unless the patient has a history of cardiovascular disease 1.
Additional Considerations
- Anticoagulation therapy, such as warfarin, should be interrupted at presentation, and reversed with prothrombin complex in cases of unstable gastrointestinal hemorrhage 1.
- The use of proton pump inhibitors, such as pantoprazole or esomeprazole, may be considered in certain cases, although the provided evidence does not specifically address their use in the context of GI bleed management 1. Overall, the goal of treatment is to promptly stabilize the patient, identify the source of bleeding, and provide appropriate intervention to prevent morbidity and mortality.
From the Research
Treatment Guidelines for Possible GI Bleed
The treatment guidelines for a possible gastrointestinal (GI) bleed involve several steps, including:
- Assessment of hemodynamic stability and resuscitation with intravenous fluids and blood transfusions as needed 2, 3, 4
- Use of proton pump inhibitors (PPIs) to reduce gastric acid production and prevent ulcer rebleeding 2, 3, 5, 4
- Endoscopy to diagnose and treat the cause of the GI bleed, which should be performed within 24 hours of presentation 2, 3, 4
- Endoscopic treatment, such as ligation, thermal probes, or clips, for variceal bleeding or high-risk non-variceal bleeding 2
- Pharmacologic management, including antibiotics and vasoactive drugs, for patients with cirrhosis or variceal bleeding 2
- Consideration of surgery or interventional radiology for patients who require repeat endoscopic therapy or have recurrent bleeding 2, 3, 4
Management of Recurrent GI Bleed
For patients with recurrent GI bleed, treatment options may include:
- Repeat endoscopic therapy 2
- Use of octreotide, a somatostatin analogue, to reduce bleeding 6
- Transcatheter arterial embolization or surgery for patients with failed endoscopic hemostasis 4
- Consideration of restarting antithrombotic therapy after upper GI bleeding, although the optimal timing is unclear 4
Risk Stratification and Prediction Guides
Clinical prediction guides, such as the Glasgow-Blatchford bleeding score, can be used to stratify patients with upper GI bleeding and determine the need for urgent endoscopy or other interventions 4