How to manage a patient with pulmonary embolism (PE) and gastrointestinal bleeding (GIB)?

Management of Pulmonary Embolism with Concomitant Gastrointestinal Bleeding

In patients with pulmonary embolism (PE) and active gastrointestinal bleeding (GIB), unfractionated heparin (UFH) should be used as the initial anticoagulant due to its short half-life and ability to be rapidly reversed if bleeding worsens. 1

Risk Stratification and Initial Assessment

1. Assess hemodynamic stability and PE severity:

   • High-risk PE: Hypotension (systolic BP <90 mmHg) or shock
   • Intermediate-risk PE: Normotensive with RV dysfunction
   • Low-risk PE: Normotensive without RV dysfunction

2. Evaluate GIB severity:

   • Active bleeding with hemodynamic instability
   • Active bleeding without hemodynamic compromise
   • Recent bleeding that has stopped

Management Algorithm

For High-Risk PE with Active GIB:

1. Stabilize hemodynamics:

   • Fluid resuscitation and blood products as needed
   • Vasopressors if necessary

2. Anticoagulation approach:

   • Start UFH with careful dosing (consider lower initial bolus of 60-70 U/kg)
   • Target lower aPTT range (1.5-2.0 times control) 1
   • Avoid thrombolytics due to high bleeding risk 2

3. Consider mechanical interventions if anticoagulation contraindicated:

   • IVC filter placement (temporary) 1
   • Catheter-directed mechanical thrombectomy without thrombolytics 3

4. Urgent GIB management:

   • Endoscopic intervention to identify and treat bleeding source
   • Consider interventional radiology for embolization if endoscopy fails

For Intermediate/Low-Risk PE with Active GIB:

1. GIB management first:

   • Identify and treat bleeding source
   • Stabilize hemoglobin

2. Anticoagulation approach:

   • Once bleeding is controlled, start UFH with careful monitoring 4
   • Lower intensity anticoagulation may be considered
   • If proximal DVT has been excluded and bleeding risk remains high, temporary withholding of anticoagulation may be considered 4

3. Transitioning to long-term anticoagulation:

   • Once GIB is resolved, transition to LMWH or warfarin
   • Avoid DOACs in patients with history of GI bleeding, especially with GI cancer 4

Special Considerations

For Massive PE Despite GIB:

• If cardiac arrest is imminent, consider reduced-dose thrombolysis (e.g., 50% of standard dose) despite bleeding risk 4, 2
• Surgical embolectomy may be considered in centers with expertise 4

For Recurrent PE Despite Anticoagulation:

• Consider higher target INR (3.0-3.5) once GIB is resolved 4
• Consider LMWH as long-term alternative to oral anticoagulation 1

Monitoring Requirements:

• Daily CBC to monitor hemoglobin and hematocrit
• More frequent aPTT monitoring (every 6 hours initially)
• Regular clinical assessment for signs of ongoing bleeding or PE progression

Common Pitfalls and Caveats

• Don't withhold all anticoagulation indefinitely: The mortality risk from untreated PE often exceeds bleeding risk; use reduced intensity when possible rather than complete cessation
• Avoid aspirin co-administration: This significantly increases bleeding risk 4
• Remember that elderly patients with peptic ulcer disease have higher bleeding rates on anticoagulation 4
• Don't use DOACs in patients with GI cancer due to increased bleeding risk 4
• Temporary IVC filters should be removed as soon as anticoagulation can be safely initiated to prevent filter thrombosis 1

By following this structured approach, clinicians can balance the competing risks of thromboembolism and bleeding in this challenging clinical scenario, prioritizing interventions that minimize mortality while maintaining vigilance for complications.