What is the initial workup and management for a patient presenting with a gastrointestinal (GI) bleed?

Initial Workup and Management of Gastrointestinal Bleeding

The initial management of a patient with gastrointestinal bleeding should include immediate hemodynamic assessment using shock index (heart rate/systolic BP), aggressive fluid resuscitation, followed by diagnostic procedures to localize bleeding, and prompt intervention based on the source of bleeding. 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
• Place at least two large-bore intravenous catheters to allow rapid volume expansion 2
• Initiate fluid resuscitation with crystalloids to restore and maintain hemodynamic stability 2
• Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL for most patients 1, 2
• Consider higher transfusion threshold (Hb 8 g/dL, target ≥10 g/dL) for patients with cardiovascular disease 1, 3
• Perform digital rectal examination as part of the initial assessment to evaluate for anorectal causes of bleeding 1

Diagnostic Approach

• For hemodynamically stable patients, perform upper and lower GI endoscopy as the initial diagnostic procedure 2
• For hemodynamically unstable patients (shock index >1), perform CT angiography immediately to localize bleeding before any intervention 1, 3
• Always consider an upper GI source in patients with hemodynamic instability, as failure to do so can lead to delayed diagnosis and treatment 1, 3
• For patients with suspected variceal bleeding, initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) as soon as bleeding is suspected 2

Management Based on Hemodynamic Status

For Hemodynamically Unstable Patients:

• Perform immediate surgery in patients with hemorrhagic shock who are non-responders to resuscitation 2
• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes for hemodynamically unstable patients in centers with 24/7 interventional radiology 1, 3

For Hemodynamically Stable Patients:

• Perform endoscopy within 24 hours after presentation 2, 4
• Consider administering erythromycin infusion before endoscopy to improve visualization 4
• For patients with lower GI bleeding, calculate the Oakland score to guide management decisions 3
• Patients with Oakland score ≤8 points can be safely discharged for urgent outpatient investigation 3
• Patients with Oakland score >8 points should be admitted for colonoscopy 3

Management of Anticoagulation and Antiplatelet Therapy

• For patients on warfarin with unstable GI hemorrhage, interrupt warfarin therapy immediately and reverse anticoagulation with prothrombin complex concentrate and vitamin K 1, 3
• For patients with low thrombotic risk, restart warfarin 7 days after hemorrhage 1, 3
• For patients with high thrombotic risk, consider low molecular weight heparin therapy at 48 hours after hemorrhage 1
• For patients on aspirin for primary prophylaxis, aspirin should be permanently discontinued 1, 3
• For patients on aspirin for secondary prevention, aspirin should not be routinely stopped; if stopped, restart as soon as hemostasis is achieved 1, 3

Endoscopic Management

• Provide endoscopic hemostasis therapy to patients with high-risk endoscopic stigmata including active bleeding, non-bleeding visible vessel, or adherent clot 4
• For ulcer bleeding, recommended endoscopic therapies include bipolar electrocoagulation, heater probe, and absolute ethanol injection 4
• After endoscopic hemostasis for ulcer bleeding, administer high-dose proton pump inhibitor therapy continuously or intermittently for 3 days 4
• For variceal bleeding, use endoscopic band ligation for esophageal varices and tissue glue for gastric varices 5
• Consider repeat endoscopy for recurrent bleeding 2, 4

Common Pitfalls to Avoid

• Failing to consider an upper GI source in patients with hemodynamic instability 1, 3
• Delaying endoscopy beyond 24 hours in high-risk patients 2
• Using high doses of non-selective beta-blockers in patients with severe or refractory ascites 2
• Overlooking the need for antibiotic prophylaxis in patients with cirrhosis and GI bleeding 2
• Underestimating mortality risk, which is generally related to comorbidity rather than exsanguination 1, 3