What is the full inpatient management of a suspected Gastrointestinal (GI) bleed?

Inpatient Management of Suspected GI Bleeding

The comprehensive management of suspected GI bleeding requires immediate initiation of high-dose proton pump inhibitor therapy, prompt endoscopic evaluation within 24 hours, and appropriate blood transfusion targeting hemoglobin levels of 70-100 g/L. 1

Initial Assessment and Stabilization

1. Hemodynamic Assessment and Resuscitation

   • Assess vital signs, mental status, and signs of shock
   • Establish large-bore IV access (two 18G or larger)
   • Administer crystalloid fluids for resuscitation if hemodynamically unstable
   • Place patient on cardiac monitoring

2. Laboratory Evaluation

   • Complete blood count (CBC)
   • Coagulation profile (PT/INR, PTT)
   • Comprehensive metabolic panel
   • Type and cross-match for potential blood transfusion
   • Consider lactate level for patients with signs of shock

3. Blood Transfusion Strategy

   • Transfuse packed red blood cells if hemoglobin <70 g/L (target 70-100 g/L)
   • Consider higher transfusion threshold (>80 g/L) for patients with cardiovascular disease
   • Avoid over-transfusion as it may increase risk of rebleeding 1

Medication Management

1. Acid Suppression

   • Start high-dose proton pump inhibitor (PPI) therapy immediately
   • Bolus followed by continuous infusion improves endoscopic visualization and reduces risk of continued bleeding 1

2. Management of Antithrombotic Medications

   • Immediately interrupt both anticoagulant and antiplatelet therapy
   • Consider reversal agents for life-threatening hemorrhage:
     • Vitamin K, prothrombin complex concentrate, or fresh frozen plasma for warfarin
     • Specific reversal agents for direct oral anticoagulants in severe cases
   • Consult cardiology regarding timing of medication resumption 1

3. Prokinetic Agents

   • Consider IV erythromycin (250 mg) 30-60 minutes before endoscopy to improve visualization 2

4. Antibiotics for Cirrhotic Patients

   • Initiate prophylactic antibiotics if cirrhosis is suspected 1, 2

Diagnostic Workup

1. Endoscopic Evaluation

   • Perform upper GI endoscopy within 24 hours of presentation
   • Consider earlier endoscopy (<12 hours) for high-risk patients (hemodynamic instability, active bleeding)
   • Use cap-fitted endoscopy to examine blind areas, especially the C-loop of duodenum
   • Pay special attention to commonly overlooked lesions like gastric antral vascular ectasia 1

2. If Upper GI Endoscopy is Negative

   • Proceed with colonoscopy after adequate bowel preparation
   • Consider small bowel evaluation with capsule endoscopy, especially in patients >40 years where vascular lesions comprise up to 40% of small intestinal bleeding causes 1

3. Radiological Evaluation

   • CT Angiography (CTA) has high sensitivity (80-90%) for detecting active bleeding at rates as low as 0.3-1.0 mL/min
   • Nuclear medicine studies (tagged RBC scan) may be considered for intermittent or slow bleeding
   • Mesenteric angiography for hemodynamically unstable patients with negative CTA 1, 3

Therapeutic Interventions

1. Endoscopic Therapy

   • For non-variceal bleeding:
     • Clips, thermal therapy, or injection therapy for active bleeding or visible vessels
     • Combination therapy may be more effective than single modality
   • For variceal bleeding:
     • Ligation for esophageal varices
     • Tissue glue for gastric varices 1, 2

2. Interventional Radiology

   • Angiographic embolization for persistent bleeding despite endoscopic therapy
   • Particularly effective for diverticular bleeding and angiodysplasia 1

3. Surgical Intervention

   • Consider if bleeding persists despite other interventions
   • Indicated when patient requires >6 units of blood or has recurrent severe bleeding 1

Ongoing Management and Disposition

1. Level of Care Determination

   • Admit to appropriate level based on severity:
     • ICU: Hemodynamically unstable, active bleeding, significant comorbidities
     • Step-down unit: Stabilized but high risk for rebleeding
     • Regular ward: Stable, low risk for rebleeding 1, 4

2. Monitoring

   • Continuous vital sign monitoring
   • Serial hemoglobin measurements
   • Stool monitoring for continued bleeding

3. Risk Stratification for Discharge

   • Oakland score ≤8 points identifies patients who can be safely discharged for outpatient follow-up 1

4. Follow-up Planning

   • Iron supplementation for patients discharged with anemia
   • Outpatient follow-up within 2 weeks for endoscopic evaluation in stable patients
   • Age-appropriate cancer screening as GI malignancies can present with bleeding 1

Special Considerations

1. Dual Pathology

   • Consider lesions in both upper and lower GI tracts (occurs in 10-15% of patients)
   • Comprehensive assessment is necessary even after identifying one source 1

2. Elderly Patients

   • Iron deficiency often multifactorial
   • Higher prevalence of malignancy and dual unrelated pathology 1

3. Common Pitfalls to Avoid

   • Delaying diagnosis leads to poor outcomes and increased costs
   • Incomplete examination misses up to 15% of bleeding sources
   • Failure to recognize that severe hematochezia may have an upper GI source (in up to 15% of cases) 1
   • Over-transfusion may increase risk of rebleeding 5