What is the initial management and treatment for a gastrointestinal (GI) bleed?

Initial Management of Gastrointestinal Bleeding

The initial management of a gastrointestinal (GI) bleed should begin with immediate assessment of hemodynamic status, fluid resuscitation, and risk stratification to guide subsequent diagnostic and therapeutic interventions. 1

Initial Assessment and Resuscitation

• Immediately assess hemodynamic status using shock index (heart rate/systolic BP), with a shock index >1 indicating instability requiring urgent intervention 1
• Start intravenous fluid resuscitation with normal saline or lactated Ringer solution for patients with hypovolemia 2
• Transfuse red blood cells using restrictive thresholds:
  • Hemoglobin trigger of 70 g/L (target 70-90 g/L) for patients without cardiovascular disease 1
  • Hemoglobin trigger of 80 g/L (target 100 g/L) for patients with cardiovascular disease 1
• Correct coagulopathy (INR >1.5) or thrombocytopenia (<50,000/μL) with fresh frozen plasma or platelets respectively 3
• Patients with persistent hemodynamic instability despite aggressive resuscitation require immediate intervention 3

Risk Stratification

• For hemodynamically stable patients with lower GI bleeding, calculate the Oakland score to guide management decisions 1
  • Includes age, gender, previous LGIB admission, digital rectal examination findings, heart rate, systolic blood pressure, and hemoglobin level 1
  • Oakland score ≤8: patient can be safely discharged for urgent outpatient investigation 1
  • Oakland score >8: patient should be admitted for colonoscopy 1
• Patients with hematochezia and hemodynamic instability should be evaluated for possible upper GI source (10-15% of apparent lower GI bleeding cases) 4

Diagnostic Approach

For Hemodynamically Unstable Patients:

• CT angiography (CTA) should be performed immediately as the first-line investigation to localize bleeding 1, 4
• Following positive CTA, catheter angiography with embolization should be performed within 60 minutes for hemodynamically unstable patients 1

For Hemodynamically Stable Patients:

• Direct anorectal inspection with anoscopy should be performed first when bright red rectal bleeding is present 4
• Endoscopy should be performed within 24 hours after adequate resuscitation 5
• For suspected upper GI bleeding, proton pump inhibitors (PPIs) should be initiated upon presentation 2
• For suspected variceal bleeding in patients with cirrhosis, administer antibiotics and vasoactive drugs 6

Management of Specific Bleeding Types

Upper GI Bleeding:

• Endoscopic treatment for high-risk non-variceal bleeding includes injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel 6
• For variceal bleeding, use ligation for esophageal varices and tissue glue for gastric varices 6
• High-dose proton pump inhibitors should be administered after endoscopy for ulcer bleeding 6

Lower GI Bleeding:

• Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata including active bleeding, non-bleeding visible vessel, or adherent clot 5
• The hemostasis modality used (mechanical, thermal, injection, or combination) depends on bleeding etiology, access to the bleeding site, and endoscopist experience 5

Management of Anticoagulation and Antiplatelet Therapy

• For patients on warfarin, interrupt therapy at presentation and reverse anticoagulation with prothrombin complex concentrate and vitamin K for unstable GI hemorrhage 1
• For patients with low thrombotic risk, restart warfarin 7 days after hemorrhage 1
• For patients on aspirin for primary prophylaxis, permanently discontinue; for secondary prevention, do not routinely stop or restart as soon as hemostasis is achieved 1

Common Pitfalls to Avoid

• Failing to consider an upper GI source in patients with severe hematochezia and hypovolemia 4
• Delaying appropriate imaging in unstable patients while attempting bowel preparation for colonoscopy 4
• Proceeding directly to colonoscopy without first examining the anorectal region 4
• Using nasogastric tube placement to rule out upper GI bleeding (not reliable) 4