What is the management approach for a patient with a stroke and an upper gastrointestinal (GI) bleed?

Management of Stroke with Upper GI Bleeding

In patients with stroke and upper gastrointestinal bleeding, immediate hemodynamic stabilization followed by early endoscopy within 24 hours is the recommended approach, with careful consideration of antiplatelet/anticoagulant management based on stroke and bleeding risk. 1

Initial Assessment and Stabilization

Hemodynamic Resuscitation

• Initiate immediate fluid resuscitation with crystalloids (1-2 liters of normal saline) through two large-bore IV cannulae (16-18G) 1
• Target parameters: mean arterial pressure >65 mmHg, urine output >30 mL/hour 1
• Monitor vital signs hourly, with particular attention to:
  • Pulse rate (>100 beats/min indicates severe bleeding)
  • Systolic blood pressure (<100 mmHg indicates severe bleeding)
  • Hemoglobin concentration (<100 g/L indicates severe bleeding) 1

Blood Transfusion Strategy

• Maintain hemoglobin levels between 7-9 g/dL 2
• Transfuse red blood cells when hemoglobin falls below 7 g/dL 2
• A higher threshold should be considered in patients with cardiovascular disease 2

Risk Stratification

For GI Bleeding

• Use the Glasgow Blatchford Score (GBS) for pre-endoscopy risk stratification 1
• Assess for signs of active bleeding:
  • Fresh melena or hematemesis
  • Fall in blood pressure
  • Rise in pulse rate 1

For Stroke

• Determine stroke severity using NIHSS score
• Higher NIHSS scores (≥8) are associated with increased risk of GI bleeding 2, 3
• Previous history of peptic ulcer disease significantly increases risk of GI bleeding 3

Diagnostic Approach

Endoscopy

• Perform upper endoscopy within 24 hours of presentation after initial hemodynamic stabilization 1, 2
• For patients with severe bleeding, consider more urgent endoscopy (within 12 hours) 1
• Nasogastric tube placement is not routinely recommended as it does not reliably aid diagnosis 1

Identify Cause of Bleeding

• Common causes include:
  • Peptic ulceration (28%)
  • Malignancies (12%)
  • Medication-induced (NSAIDs, antiplatelet agents, anticoagulants) 3, 4
• Note that GI bleeding typically occurs within 1 week after stroke onset 3

Management Strategy

For Upper GI Bleeding

• Administer high-dose proton pump inhibitor therapy:
  • Omeprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours, or
  • Pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion 1
• For endoscopically confirmed high-risk lesions, perform endoscopic hemostasis using:
  • Clips or thermocoagulation (alone or with epinephrine injection)
  • Note: Epinephrine injection alone is not recommended 2

Antiplatelet/Anticoagulant Management

• For patients requiring antiplatelet therapy for secondary stroke prevention:
  • Temporarily discontinue antiplatelet agents during active bleeding
  • Resume acetylsalicylic acid (ASA) as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 2
  • ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 2
• For patients on dual antiplatelet therapy (DAPT):
  • Consider GI protection with PPI in patients at higher risk of GI bleeding 2
  • If DAPT is required for recent minor stroke/TIA, resume as soon as bleeding is controlled

Nutritional Support

• For patients with high risk of rebleeding (Forrest I-IIb) or variceal bleeding:
  • Wait at least 48 hours after endoscopic therapy before initiating oral or enteral feeding 5
• For patients with low risk of rebleeding (Forrest IIc and III), gastritis, or esophagitis:
  • Resume feeding as soon as tolerated 5

Monitoring and Follow-up

Post-Endoscopy Care

• Admit high-risk patients to a monitored setting (ICU or high dependency unit) for at least the first 24 hours 2
• Monitor for signs of rebleeding for at least 72 hours after endoscopic hemostasis 2
• Allow hemodynamically stable patients to drink and start a light diet 4-6 hours after endoscopy 1

Long-term Considerations

• GI bleeding during acute stroke hospitalization increases the risk of stroke recurrence at 3,6, and 12 months 6
• GI bleeding is independently associated with:
  • Neurologic deterioration (OR 3.9)
  • In-hospital death (OR 6.1)
  • Poor functional outcome at 3 months (OR 6.8) 3

Special Considerations

For Patients on Thrombolytic Therapy

• In patients treated with tissue plasminogen activator (alteplase), GI bleeding is a serious potential complication 7
• Exercise caution with patients who have active internal bleeding or recent procedures 7
• If serious GI bleeding occurs, stop thrombolytic treatment immediately 7

For Patients with Recurrent Bleeding

• Attempt repeat endoscopic therapy once for rebleeding after initial endoscopic therapy
• Consider surgery if second rebleeding occurs or if endoscopic therapy fails 1

For Patients with Stroke and Comorbidities

• Patients with multiple comorbidities have significantly higher mortality risk 2
• Consider early involvement of multidisciplinary team including gastroenterology, neurology, and critical care 2