What is the management plan for a patient with a possible gastrointestinal (GI) bleed?

Management of Possible Gastrointestinal Bleeding

The management of a patient with possible gastrointestinal (GI) bleeding should begin with hemodynamic stabilization, followed by early endoscopy within 24 hours, using a restrictive blood transfusion strategy with a hemoglobin trigger of <70 g/L (target 70-90 g/L) for most patients, and a higher threshold of 80 g/L for patients with cardiovascular disease. 1

Initial Resuscitation and Assessment

1. Hemodynamic Stabilization:

   • Maintain mean arterial pressure >65 mmHg while avoiding fluid overload
   • Assess coagulation parameters and correct coagulopathy with appropriate blood products
   • Implement restrictive blood transfusion strategy (Hb <70 g/L, target 70-90 g/L)
   • For patients with cardiovascular disease, use higher threshold (Hb <80 g/L, target 100 g/L)

2. Medication Management:

   • Direct Oral Anticoagulants (DOACs): Interrupt therapy at presentation 2
   • For life-threatening hemorrhage on DOACs, consider reversal agents such as idarucizumab (for dabigatran) or andexanet (for anti-factor Xa inhibitors) 2
   • For patients on dual antiplatelet therapy with active bleeding, continue aspirin without interruption but temporarily discontinue P2Y12 receptor antagonist 1

Diagnostic Evaluation

1. Digital Rectal Examination and Anoscopy to assess for lower GI sources 1

2. Endoscopy:

   • Upper endoscopy for suspected upper GI bleeding
   • Colonoscopy for suspected lower GI bleeding (72-86% diagnostic accuracy) 1
     • Should be performed after adequate bowel preparation
     • Complete to the cecum with high-quality examination
   • Video capsule endoscopy if small bowel source is suspected (highest yield when performed within 48 hours) 1

3. Radiological Assessment:

   • CT angiography for suspected thrombotic causes or when endoscopy is not immediately available 1, 3
   • Conventional angiography for hemodynamically unstable patients where diagnosis and treatment can be performed simultaneously 3

Therapeutic Interventions

1. Endoscopic Treatment:

   • First-line for identified bleeding sources
   • Options include clipping, thermal therapy, injection therapy, and band ligation 1
   • For variceal bleeding: ligation for esophageal varices and tissue glue for gastric varices 4

2. Pharmacological Therapy:

   • Proton pump inhibitors (PPIs) for upper GI bleeding or high-risk endoscopic findings 1, 4
   • Antibiotics and vasoactive drugs for patients with cirrhosis and variceal bleeding 4

3. Interventional Radiology:

   • Angiographic embolization if endoscopic treatment fails (technical success rates 93-100%, but 10-50% risk of rebleeding) 1

4. Surgical Intervention:

   • Reserved for cases where endoscopic and radiological interventions fail
   • No patient should proceed to emergency laparotomy without attempts to localize bleeding by radiological and/or endoscopic modalities 1

Management of Anticoagulants and Antiplatelets

1. DOACs:

   • Interrupt at presentation 2
   • Consider restarting at maximum of 7 days after bleeding has stopped 2
   • For patients at high risk of rebleeding, consider switching to warfarin due to more effective reversal options 2

2. Antiplatelet Therapy:

   • For secondary prevention, aspirin should be continued or restarted as soon as hemostasis is achieved 1
   • For dual antiplatelet therapy, maintain aspirin and temporarily discontinue P2Y12 inhibitor 1

Follow-up and Prevention

1. Iron Supplementation for patients discharged with anemia 1

2. Follow-up:

   • Gastroenterology follow-up within 2 weeks if discharged
   • Cardiology follow-up to assess stent status and optimize antiplatelet regimen for relevant patients 1

3. H. pylori Testing and Eradication if positive 1

Special Considerations

• Lower GI Bleeding in Patients on Anticoagulants/Antiplatelets:

  • Associated with more severe bleeding (55.1% vs. 35.4% in non-users) 5
  • Higher likelihood of requiring blood transfusions (68% vs. 51.5%) 5
  • Longer hospital stays (>6 days: 44% vs. 27.3%) 5
  • Higher rate of in-hospital complications (37% vs. 22.7%) 5

• Recurrent Bleeding:

  • For ulcer bleeding: repeat endoscopic therapy; subsequent bleeding managed by interventional radiology or surgery 4
  • For recurrent variceal bleeding: consider transjugular intrahepatic portosystemic shunt 4

• Nonsteroidal Anti-inflammatory Drugs (NSAIDs):

  • Should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia 6