What to do after a gastrointestinal (GI) bleed has resolved on its own?

Management After Self-Resolved Gastrointestinal Bleeding

After a gastrointestinal (GI) bleed has resolved on its own, patients should undergo diagnostic evaluation with colonoscopy within 24 hours of presentation to identify the bleeding source and prevent recurrence, followed by appropriate targeted therapy based on the underlying cause. 1, 2

Initial Assessment and Risk Stratification

• Assess hemodynamic stability and perform risk stratification using clinical parameters to distinguish patients at high vs. low risk of adverse outcomes
• Check hemoglobin levels and consider iron supplementation if anemia is present 3
• Determine if bleeding was from upper or lower GI tract based on clinical presentation (hematemesis suggests upper GI source, while hematochezia typically indicates lower GI source)
• Note: Hematochezia with hemodynamic instability may indicate an upper GI source and warrants upper endoscopy 2

Diagnostic Approach

1. Colonoscopy: First-line diagnostic procedure for lower GI bleeding

   • Should be performed within 24 hours after adequate bowel preparation 2
   • Has high diagnostic yield for identifying bleeding source
   • Allows for both diagnosis and therapeutic intervention

2. If colonoscopy is negative or bleeding source is suspected to be in small bowel:

   • Video capsule endoscopy (VCE) should be the next diagnostic modality 1
   • Highest diagnostic yield (87-91.9%) when performed within 48 hours of bleeding 1
   • Yield drops to <50% if performed beyond 3 days of presentation 1

3. For patients unable to undergo colonoscopy or with ongoing bleeding:

   • CT angiography (CTA) can detect bleeding at rates of 0.3-1.0 mL/min 3
   • Mesenteric angiography may be considered but has limited yield in hemodynamically stable patients with negative CTA 3

Management Based on Bleeding Source

Diverticular Bleeding

• Most diverticular bleeding stops spontaneously (80% of cases) 1
• If recurrent bleeding occurs, endoscopic options include:
  • Injection therapy (epinephrine)
  • Endoscopic clipping (through-the-scope or over-the-scope)
  • Thermal therapies (bipolar coagulation or argon plasma coagulation)
  • Endoscopic band ligation 1

Post-Polypectomy Bleeding

• Colonoscopy should be first-line investigation and treatment
• Consider combination therapy with epinephrine plus another modality (mechanical or thermal) 1

Angiodysplasia

• Endoscopic ablation is preferred for accessible lesions
• Consider hormonal therapy or octreotide for recurrent bleeding 3

Small Bowel Sources

• Push enteroscopy may be considered if VCE identifies a bleeding source
• Note that VCE has superior diagnostic yield compared to push enteroscopy (50% vs 24%) 1

Prevention of Recurrent Bleeding

1. Medication Management:

   • Avoid NSAIDs in patients with history of GI bleeding, particularly if secondary to diverticulosis or angiodysplasia 2
   • For patients requiring antiplatelet therapy:
     • Continue aspirin without interruption if used for secondary cardiovascular prophylaxis 3, 2
     • If on dual antiplatelet therapy, resume P2Y12 receptor antagonist within 5 days after achieving hemostasis 3

2. Gastroprotection:

   • Proton pump inhibitors (PPIs) are superior to H2-receptor antagonists for preventing GI bleeding in patients on antiplatelet therapy 3
   • Continue PPI therapy when antiplatelet therapy is resumed, especially in high-risk patients 3

3. Follow-up:

   • Schedule gastroenterology follow-up within 2 weeks of discharge 3
   • Consider screening for H. pylori and eradication if positive 3

Special Considerations

• For patients with coronary stents requiring antiplatelet therapy:

  • Balance bleeding risk against thrombotic risk
  • If antiplatelet therapy was temporarily discontinued, resume within 5 days after achieving hemostasis 3
  • Cardiology follow-up to assess stent status and optimize antiplatelet regimen is crucial 3

• For patients with anemia:

  • Iron supplementation should be provided with expected response rates of 80-90% 3
  • Target hemoglobin level of 7-9 g/dL for transfusion decisions 3

When to Consider Surgery

Surgery should be considered only after failed endoscopic and radiological interventions, particularly if:

• Bleeding persists despite other interventions
• Patient requires >6 units of blood
• Patient experiences recurrent severe bleeding 3

Surgery without prior localization of bleeding by radiological and/or endoscopic modalities should be avoided 3