What is the assessment and management plan for a patient admitted with a gastrointestinal (GI) bleed?

Assessment and Management Plan for GI Bleeding

For patients admitted with gastrointestinal bleeding, immediate assessment of hemodynamic status, prompt resuscitation, identification of bleeding source, and appropriate management of medications are essential for reducing morbidity and mortality.

Initial Assessment

• Assess vital signs, hemoglobin, hematocrit levels, and coagulation status 1
• Stratify severity of bleeding:
  • Minor bleeding
  • Intermittent chronic bleeding
  • Severe episodes with stability between episodes
  • Active continuous bleeding 1
• Note that in-hospital mortality is 3.4%, rising to 18% for patients who develop lower GI bleeding while hospitalized 2
• Mortality is generally related to comorbidities rather than exsanguinating hemorrhage 2

Immediate Management Orders

1. Resuscitation Orders:

   • Large-bore IV access (two sites)
   • Fluid resuscitation with crystalloids
   • Blood transfusion if hemoglobin <70-80 g/L 3
   • Consider massive transfusion protocol if shock index >1.0 or inadequate response to initial transfusion 4

2. Medication Management:

   • Antiplatelet/Anticoagulant Management:

     • Aspirin for primary prevention: Permanently discontinue 2
     • Aspirin for secondary prevention: Continue; if stopped, restart as soon as hemostasis is achieved 2
     • Dual antiplatelet therapy: Do not routinely stop in patients with coronary stents; manage in liaison with cardiology 2
     • P2Y12 receptor antagonists: If interrupted, reinstate within 5 days 2
     • Direct oral anticoagulants: Interrupt at presentation; consider reversal agents (idarucizumab, andexanet) for life-threatening hemorrhage 2

   • Other Medications:

     • Discontinue NSAIDs 1
     • Consider proton pump inhibitors (PPIs) 1
     • For suspected variceal bleeding: antibiotics and somatostatin analogues 5

Diagnostic Workup Orders

1. Endoscopy:

   • Upper endoscopy and/or colonoscopy within 24 hours of presentation 1, 3
   • Earlier endoscopy after resuscitation for high-risk patients (hemodynamically unstable) 3

2. Imaging if Endoscopy Inconclusive:

   • CT angiography for stable patients with active bleeding (sensitivity 80-90%) 1
   • Conventional angiography if bleeding is active and CT inconclusive 1

Treatment Plan

1. Endoscopic Treatment:

   • For high-risk stigmata (active bleeding, visible vessel, adherent clot)
   • Options include band ligation, sclerotherapy, hemostatic clips 1

2. Interventional Radiology:

   • Angiographic embolization for ongoing bleeding not amenable to endoscopic treatment 1
   • Intra-arterial vasopressin infusion (controls bleeding in up to 91% of cases with diverticular disease or angiodysplasia) 1

3. Surgical Management:

   • Consider for:
     • Persistent hemodynamic instability despite aggressive resuscitation
     • Requirement of >6 units of blood transfusion
     • Recurrence of severe bleeding 1

Follow-up Plan

1. Medication Resumption:

   • Restart direct oral anticoagulants at maximum of 7 days after hemorrhage 2
   • Resume low molecular weight heparin at 48 hours after hemorrhage for patients with venous thromboembolism 2

2. Anemia Management:

   • IV iron for patients with hemoglobin <10 g/dL 1
   • Oral iron supplementation for discharged patients with anemia 1

3. Prevention of Recurrence:

   • Optimize treatment of underlying conditions
   • Consider age-appropriate cancer screening 1

Important Considerations and Pitfalls

• Anticoagulation management requires careful balancing of bleeding vs. thrombotic risks; consult with cardiology for patients with coronary stents 2
• Source identification can be challenging; up to 10-15% of severe lower GI bleeding cases actually originate from the upper GI tract 1
• Timing of endoscopy is critical; ensure adequate resuscitation before the procedure but don't delay unnecessarily 3
• Resource availability is important; hospitals admitting GI bleeding patients should have access to 7/7 on-site colonoscopy and 24/7 interventional radiology (on-site or via formal referral pathway) 2