What is the treatment for gastrointestinal (GI) bleeding?

Management of Gastrointestinal Bleeding

The treatment of gastrointestinal bleeding requires immediate resuscitation, followed by source identification and targeted intervention based on bleeding location and severity, with endoscopic therapy as the primary treatment modality for most cases.

Initial Assessment and Resuscitation

• Immediate evaluation of hemodynamic status (checking for pallor, tachycardia, hypotension, orthostatic changes) is the critical first step 1
• Establish large-bore intravenous access for fluid resuscitation with normal saline or lactated Ringer solution 1
• Transfuse packed red blood cells to maintain hemoglobin above 7 g/dL (consider 9 g/dL threshold in patients with massive bleeding or significant cardiovascular disease) 1
• Correct coagulopathy (INR >1.5) or thrombocytopenia (<50,000/μL) with fresh frozen plasma or platelets 1

Source Identification

• For hemodynamically unstable patients, proceed directly to CT angiography (CTA) as the first-line investigation 1, 2
• For stable patients with suspected upper GI bleeding, perform upper endoscopy within 24 hours of presentation 2, 1
• For suspected lower GI bleeding in stable patients, colonoscopy after bowel preparation is recommended 2
• If the source remains unclear, consider small bowel evaluation with push enteroscopy or video capsule endoscopy 2

Management Based on Bleeding Location

Upper GI Bleeding

• Administer high-dose proton pump inhibitor therapy (IV loading dose followed by continuous infusion) for 3 days after successful endoscopic therapy for high-risk lesions 2
• For actively bleeding ulcers, use endoscopic therapy with thermocoagulation, sclerosant injection, or clips 2
• Consider hemostatic powder (TC-325) as temporizing therapy, but not as sole treatment, for actively bleeding ulcers 2
• Continue oral PPI therapy twice daily through 14 days after the initial 3-day IV course, then once daily depending on the nature of the bleeding lesion 2

Lower GI Bleeding

• For diverticular bleeding or angiodysplasia, endoscopic therapy options include injection therapy, clips, or thermal therapies 2
• If endoscopic therapy fails or is not feasible, consider transcatheter arterial embolization 2
• For patients on direct oral anticoagulants (DOACs) with lower GI bleeding, interrupt therapy immediately and consider reversal agents (idarucizumab for dabigatran, andexanet for factor Xa inhibitors) for life-threatening hemorrhage 2
• Consider restarting DOAC therapy at a maximum of 7 days after hemorrhage cessation 2

Interventional Radiology

• Angiography should be considered when endoscopy fails to identify or control bleeding, particularly in patients with hemodynamic instability or transfusion requirement of >5 units of blood 2
• Transcatheter embolization can be performed during diagnostic angiography to achieve hemostasis 2
• In patients too ill to tolerate urgent surgery, transcatheter embolization provides time to stabilize the patient and prepare the bowel 2

Surgical Management

• Surgery is indicated when:
  • Hemodynamic instability persists despite aggressive resuscitation
  • Blood transfusion requirement exceeds 6 units
  • Severe bleeding recurs despite non-surgical interventions 2
• Localization of the bleeding source prior to surgery allows for targeted resection rather than total colectomy, reducing complications 2
• Surgery without localization should only be reserved for uncontrollable GI bleeding 2

Special Considerations

• For patients on antiplatelet or anticoagulant therapy, the decision to restart should be made in consultation with the prescribing physician 2
• For patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy, PPI therapy is recommended for secondary prophylaxis 2
• Tranexamic acid may be considered in acute GI bleeding, but its routine use is not currently recommended outside clinical trials 2

Common Pitfalls to Avoid

• Delaying resuscitation while pursuing diagnostic tests - resuscitation should always take precedence 1
• Assuming lower GI bleeding based solely on rectal bleeding - up to 15% of apparent lower GI bleeds are actually from upper GI sources 1
• Failing to consider an upper GI source when nasogastric aspirate contains blood 1
• Delaying endoscopy beyond 24 hours in high-risk patients 2, 1