What is the workup for a gastrointestinal (GI) bleed?

From the Guidelines

A gastrointestinal (GI) bleeding workup should begin with assessment of hemodynamic stability and resuscitation if needed, followed by upper endoscopy within 24 hours for suspected upper GI bleeding, and colonoscopy for lower GI bleeding after adequate bowel preparation, as recommended by the most recent guidelines 1. The initial evaluation should include a complete blood count, coagulation studies (PT/INR, PTT), comprehensive metabolic panel, and type and cross for potential transfusion.

• Blood transfusion is typically indicated when hemoglobin falls below 7 g/dL or for hemodynamically unstable patients.
• Medications that increase bleeding risk (NSAIDs, anticoagulants, antiplatelets) should be temporarily discontinued if possible.
• Proton pump inhibitors like pantoprazole 40mg IV twice daily are recommended for upper GI bleeding until endoscopy, as supported by previous studies 1.
• Octreotide (50-100 mcg IV bolus followed by 25-50 mcg/hour infusion) may be used for suspected variceal bleeding. The workup should also include risk stratification using tools like the Glasgow-Blatchford score to guide management decisions and determine the need for ICU admission, as suggested by earlier research 1.
• Identifying and treating the underlying cause is essential for preventing recurrence, whether it's peptic ulcer disease, varices, diverticulosis, or other conditions. For obscure bleeding, video capsule endoscopy, CT angiography, or tagged red blood cell scans may be necessary, as outlined in older studies 1. It is crucial to prioritize the most recent and highest quality study, which in this case is the 2024 update on nonvariceal upper gastrointestinal bleeding 1, to ensure the best possible outcome in terms of morbidity, mortality, and quality of life.

From the Research

Initial Assessment and Resuscitation

• The initial management of a patient with gastrointestinal (GI) bleeding involves supporting the circulation of the shocked patient rather than identifying the source of bleeding 2.
• Remote damage control resuscitation, including early correction of coagulopathy and anemia, may benefit exsanguinating patients with GI bleeding 3.
• Prehospital transfusion of packed red blood cells (pRBC) and/or plasma can improve hemodynamic instability, coagulopathy, and anemia in patients with acute GI bleeding 3.

Diagnostic Evaluation

• Endoscopy is the essential tool for the diagnosis and treatment of active upper GI hemorrhage 4.
• After resuscitation, the patient can undergo an endoscopy procedure to identify the source of bleeding 2.
• The most common cause of upper GI bleeding is peptic ulcer disease, which can be diagnosed and treated during endoscopy 4, 5.

Medical Therapy

• Endoscopic therapy together with proton pump inhibitors and eradication of Helicobacter pyli significantly reduces rebleeding rates, mortality, and the number of emergency surgical interventions 4.
• A care bundle has been developed for rapid assessment and management of patients with acute upper GI bleeding, which includes medical therapy and endoscopic treatment 5.
• Patients with GI bleeding may require additional inpatient interventions and/or transfusions, suggesting that pre-hospital transfusion is being utilized for appropriately selected patients 3.