What are the signs and management of gastrointestinal (GI) bleeding?

Signs and Management of Gastrointestinal Bleeding

Patients presenting with gastrointestinal bleeding should be immediately stratified as hemodynamically stable or unstable using shock index (heart rate/systolic BP), with a shock index >1 indicating instability requiring urgent intervention. 1, 2

Clinical Signs of GI Bleeding

Presentation Signs

• Hematemesis (vomiting blood), melena (dark, tarry stools), or hematochezia (bright red blood per rectum) are the primary visible signs of GI bleeding 3
• Pallor, fatigue, chest pain, palpitations, dyspnoea, tachypnoea, tachycardia, postural changes, or syncope suggest hemodynamic compromise 3
• Digital rectal examination findings are crucial for confirming bleeding and may detect approximately 40% of rectal carcinomas 3, 1

Risk Stratification

• Use the Oakland score for stable patients with lower GI bleeding to determine management pathway 3, 2
• Oakland score components include age, gender, previous LGIB admission, digital rectal examination findings, heart rate, systolic blood pressure, and hemoglobin level 3
• Patients with Oakland score ≤8 points can be safely discharged for urgent outpatient investigation 3, 2
• Patients with Oakland score >8 points should be admitted for inpatient management 3, 2

Initial Management

Resuscitation (Priority for Unstable Patients)

• Place at least two large-bore IV catheters for rapid volume expansion 4
• Initiate fluid resuscitation with crystalloids to restore hemodynamic stability 4
• For patients requiring blood transfusion:
  • Use restrictive transfusion threshold (Hb trigger 70 g/L, target 70-90 g/L) for patients without cardiovascular disease 1, 2
  • Use higher threshold (Hb trigger 80 g/L, target ≥100 g/L) for patients with cardiovascular disease 1, 2
• Correct coagulopathy (INR >1.5) or thrombocytopenia (<50,000/μL) with fresh frozen plasma or platelets respectively 3

Diagnostic Approach

• For hemodynamically unstable patients (shock index >1), perform CT angiography immediately to localize bleeding before any intervention 1, 2, 4
• Always consider an upper GI source in patients with hemodynamic instability, even with apparent lower GI bleeding 1, 4
• For stable patients with suspected lower GI bleeding, colonoscopy is the preferred diagnostic modality 3
• If urgent colonoscopy is needed, prepare the colon with a rapid purge using 4-6 liters of polyethylene glycol solution over 3-4 hours 3

Management Based on Bleeding Source

Lower GI Bleeding

• For diverticular bleeding, endoscopic options include:
  • Injection therapy (epinephrine)
  • Endoscopic clipping (through- and over-the-scope)
  • Thermal therapies (bipolar coagulation or argon plasma coagulation)
  • Endoscopic band ligation 3

Post-Polypectomy Bleeding

• As the source is known, colonoscopy rather than CTA should be first-line investigation and treatment, even in unstable patients 3
• Combination therapy with epinephrine plus another modality (clip, thermal) is recommended 3

Obscure GI Bleeding

• For patients with negative upper and lower endoscopy but ongoing bleeding, video capsule endoscopy should be performed within 48 hours of presentation for highest diagnostic yield (87-91.9%) 3

Management of Medications

Anticoagulation Management

• For patients on warfarin with unstable GI hemorrhage:
  • Interrupt warfarin therapy immediately
  • Reverse anticoagulation with prothrombin complex concentrate and vitamin K 1, 2, 4
• For patients with low thrombotic risk, restart warfarin 7 days after hemorrhage 1, 2, 4
• For patients with high thrombotic risk, consider low molecular weight heparin therapy at 48 hours after hemorrhage 1

Antiplatelet Management

• For patients on aspirin for primary prophylaxis, permanently discontinue 1, 2
• For patients on aspirin for secondary prevention, do not routinely stop; if stopped, restart as soon as hemostasis is achieved 1, 2
• For patients on dual antiplatelet therapy, if P2Y12 receptor antagonist is stopped, reinstate within 5 days 1

Interventional Management

• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes for hemodynamically unstable patients 1, 2
• Consider surgery for patients with hemorrhagic shock who are non-responders to resuscitation 4

Mortality Risk Factors

• In-hospital mortality is approximately 3.4% overall but rises to 18% for inpatient-onset LGIB and 20% for patients requiring ≥4 units of red cells 1, 2
• Mortality in GI bleeding is generally related to comorbidity rather than exsanguination 1, 4

Common Pitfalls

• Failing to consider an upper GI source in patients with apparent lower GI bleeding and hemodynamic instability 1, 4
• Delaying endoscopy beyond 24 hours in high-risk patients 4
• Underestimating mortality risk in elderly patients and those with significant comorbidities 3, 4