What is the treatment for gastrointestinal (GI) bleeding?

Management of Gastrointestinal Bleeding

The treatment of gastrointestinal bleeding requires immediate resuscitation, risk stratification, diagnostic evaluation, and targeted interventions based on bleeding location and severity. 1, 2

Initial Assessment and Resuscitation

• Immediate evaluation of hemodynamic status with concurrent resuscitation is the critical first step in managing GI bleeding 1, 3
• Fluid resuscitation with crystalloids should be initiated in patients with hemodynamic instability to restore end-organ perfusion 2
• Blood transfusion is recommended when hemoglobin is less than 70-80 g/L, with a higher threshold for those with cardiovascular disease 2, 4
• Coagulopathy (INR >1.5) or thrombocytopenia (<50,000/µL) should be corrected with fresh frozen plasma or platelets, respectively 3
• Patients with significant bleeding should be admitted to a monitored setting for at least the first 24 hours 2

Risk Stratification

• Patients should be stratified into four categories: minor bleeding that resolves with conservative therapy, chronic intermittent bleeding, severe life-threatening bleeding with periods of stability, or continual active bleeding 3, 1
• The Glasgow Blatchford score or Oakland score can identify low-risk patients who may be suitable for outpatient management versus those requiring hospital admission 1, 2
• High-risk features include hemodynamic instability, active bleeding, and significant comorbidities 2

Diagnostic Approach

Upper GI Bleeding

• Upper endoscopy should be performed within 24 hours of presentation for suspected upper GI bleeding 2, 4
• Earlier endoscopy (within 12 hours) should be considered for high-risk patients with hemodynamic instability 2
• If the patient remains hemodynamically unstable after initial resuscitation, consider urgent CT angiography to localize bleeding 2

Lower GI Bleeding

• Colonoscopy is the diagnostic procedure of choice for acute lower GI bleeding with a diagnostic accuracy of 72-86% 1
• Urgent colonoscopy after rapid bowel cleansing is feasible and useful in patients with severe hematochezia 1, 3
• For patients with severe hematochezia, an upper GI source should be ruled out, as it accounts for 10-15% of such cases 1, 5

Therapeutic Management

Endoscopic Management

• For upper GI bleeding with high-risk stigmata, endoscopic hemostasis is indicated 2
• Combination endoscopic therapy (injection plus thermal coagulation) is superior to either treatment alone 2, 3
• For lower GI bleeding, endoscopic therapy is recommended where possible for identified bleeding sources 5

Pharmacological Management

• For upper GI bleeding, high-dose intravenous proton pump inhibitors are recommended in patients who have undergone successful endoscopic therapy 2, 3
• For suspected variceal bleeding, vasoactive drug therapy (terlipressin, somatostatin, or octreotide) should be initiated as soon as bleeding is suspected 2
• Antibiotic prophylaxis should be administered in patients with cirrhosis and suspected variceal bleeding 2

Interventional Radiology and Surgery

• Angiography is suggested for active bleeding not controlled by endoscopic means, especially after a positive bleeding scan 5
• For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended 2
• Surgical intervention is required when hemodynamic instability persists despite aggressive resuscitation, the blood transfusion requirement is greater than 6 units, or severe bleeding recurs 3

Management Algorithm

1. Assess hemodynamic status and initiate resuscitation as needed 1
2. Determine likely source of bleeding (upper vs. lower GI) based on clinical presentation 1
3. For suspected upper GI bleeding:
   • Start IV PPI therapy 2
   • Perform endoscopy within 24 hours (sooner if high-risk) 2, 4
   • Apply appropriate endoscopic therapy based on findings 2
   • Continue high-dose PPI after successful endoscopic therapy 2
4. For suspected lower GI bleeding:
   • Perform colonoscopy after bowel preparation as the first-line diagnostic procedure 1, 3
   • Consider upper endoscopy if upper GI source is suspected 1
   • If bleeding source not identified, consider radionuclide imaging followed by angiography 1
5. For persistent or recurrent bleeding:
   • Repeat endoscopic therapy 2
   • Consider angiographic embolization 5
   • Consider surgery for uncontrolled bleeding 3

Common Pitfalls and Caveats

• Failure to consider an upper GI source in patients with severe hematochezia can lead to delayed diagnosis and treatment 1
• Delayed colonoscopy may reduce diagnostic yield, particularly for identifying stigmata of recent hemorrhage 1
• Overreliance on radionuclide imaging without confirmatory tests before surgery can lead to incorrect localization 1
• For patients requiring antithrombotic agents, outcomes appear better when these drugs are reintroduced early (usually within 7 days) after bleeding control 4