What is the treatment approach for a patient with acute ischemic stroke and lower gastrointestinal (GI) bleed?

Management of Acute Ischemic Stroke with Lower GI Bleeding

For patients with acute ischemic stroke complicated by lower gastrointestinal bleeding, antiplatelet therapy should be temporarily withheld until the bleeding is controlled, then resumed as soon as possible with appropriate GI protection measures. 1

Initial Assessment and Resuscitation

• Immediate resuscitation should occur concurrently with the initial evaluation, including fluid resuscitation and blood transfusion if necessary for hemodynamic instability 1
• Assess the severity of GI bleeding through clinical parameters (hemoglobin levels, vital signs, presence of active bleeding) 1
• Stratify the patient based on bleeding severity into one of four categories: minor bleeding that resolves with conservative therapy (75-90% of cases), chronic intermittent bleeding, severe life-threatening bleeding with periods of stability, or continual active bleeding 1

Management of Lower GI Bleeding

• For patients with active lower GI bleeding, urgent diagnostic evaluation is required:

  • Colonoscopy is the first-line diagnostic tool for most patients with lower GI bleeding 1
  • For severe, ongoing bleeding with hemodynamic instability, angiography may be more appropriate 1
  • Correct coagulopathy (INR >1.5) or thrombocytopenia (<50,000/μL) with fresh frozen plasma or platelets respectively 1

• For patients with GI malignancy or recent GI bleeding (within 21 days), IV thrombolysis is contraindicated due to increased bleeding risk 1

Antiplatelet Management in Acute Ischemic Stroke with GI Bleeding

• For non-thrombolyzed patients with acute ischemic stroke, early antiplatelet therapy is generally recommended, but must be temporarily withheld in the setting of active GI bleeding 1
• Once bleeding is controlled:
  • For very high-risk TIA or minor ischemic stroke (NIHSS 0-3), dual antiplatelet therapy with clopidogrel and ASA should be initiated for 21-30 days, followed by monotherapy 1
  • For patients at higher risk of GI bleeding on dual antiplatelet therapy, GI protection should be considered 1

Nutritional Support

• Enteral diet should be started within 7 days of admission after acute stroke 1
• For patients with dysphagia, nasogastric tubes can be used initially, with percutaneous gastrostomy tubes considered for those with anticipated persistent swallowing difficulties (>2-3 weeks) 1
• Nutritional supplements should be considered for malnourished patients or those at risk of malnourishment 1

Monitoring and Prevention of Complications

• GI bleeding in acute stroke is associated with:
  • Neurologic deterioration (OR 3.9) 2
  • Increased in-hospital mortality (OR 6.1) 2
  • Poor functional outcome at 3 months (OR 6.8) 2
• Risk factors for GI bleeding in stroke patients include:
  • Previous history of peptic ulcer 2
  • Severity of baseline neurologic deficit 2
  • Advanced age 3
  • Atrial fibrillation 3

Special Considerations

• GI bleeding typically occurs within the first week after stroke onset 2
• The source is the upper GI tract in approximately 51% of cases, with peptic ulceration (28%) and malignancies (12%) being common identifiable causes 2
• Prophylactic acid-suppressing medications should be considered for high-risk patients to prevent GI bleeding 2, 3

Resumption of Antithrombotic Therapy

• Once bleeding is controlled, antiplatelet therapy should be resumed as it is critical for secondary stroke prevention 1
• For patients who received thrombolysis, antiplatelet agents should be delayed until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage 1
• In patients unable to take oral medications, ASA (80 mg daily) and clopidogrel (75 mg daily) may be given by enteral tube or ASA by rectal suppository (325 mg daily) 1