What is the treatment for a gastrointestinal bleed?

Treatment of Gastrointestinal Bleeding

The treatment of gastrointestinal bleeding requires immediate hemodynamic assessment with concurrent resuscitation as the critical first step, followed by source identification and targeted interventions based on bleeding location and severity. 1, 2

Initial Assessment and Resuscitation

• Immediately evaluate hemodynamic status (check for pallor, tachycardia, hypotension, orthostatic changes) while simultaneously initiating resuscitation 1, 2
• Establish large-bore intravenous access for fluid resuscitation with crystalloids to restore end-organ perfusion 1, 2
• Transfuse packed red blood cells when hemoglobin is less than 70-80 g/L, with a higher threshold (80-100 g/L) for patients with cardiovascular disease 1, 2
• Correct coagulopathy (INR >1.5) with fresh frozen plasma and thrombocytopenia (<50,000/µL) with platelet transfusions 3, 1
• For patients on warfarin with active bleeding, interrupt therapy and reverse anticoagulation with prothrombin complex concentrate and vitamin K 4

Risk Stratification and Diagnostic Approach

• Stratify patients into four categories: minor bleeding resolving with conservative therapy (75-90% of cases), chronic intermittent bleeding, severe life-threatening bleeding with periods of stability, or continual active bleeding 3, 1
• For suspected upper GI bleeding, perform upper endoscopy within 24 hours of presentation, with earlier endoscopy for high-risk patients with hemodynamic instability 1, 5
• For suspected lower GI bleeding in stable patients, perform colonoscopy after adequate bowel preparation 2, 4
• For hemodynamically unstable patients or those with suspected active bleeding, proceed directly to CT angiography as the first-line investigation 2, 4

Management Based on Bleeding Location

Upper GI Bleeding

• Administer high-dose proton pump inhibitors for patients with high-risk lesions 2, 6
• Apply endoscopic therapy (combination of injection, thermal, or mechanical methods) for actively bleeding ulcers or those with non-bleeding visible vessels 1, 6
• Continue high-dose proton pump inhibitors for 3 days after successful endoscopic therapy 2, 6
• For variceal bleeding, use endoscopic band ligation for esophageal varices and tissue glue for gastric varices 5, 6

Lower GI Bleeding

• Perform colonoscopy as the diagnostic procedure of choice for acute lower GI bleeding (diagnostic accuracy 72-86%) 1, 7
• Apply endoscopic therapy (injection, clips, or thermal methods) for diverticular bleeding or angiodysplasia 2, 4
• Consider transcatheter arterial embolization if endoscopic therapy fails or is not feasible, especially after a positive bleeding scan 1, 2
• For patients with Oakland score ≤8 points, consider outpatient management; for those with scores >8, admit for colonoscopy 4

Management of Persistent or Recurrent Bleeding

• For recurrent ulcer bleeding, attempt repeat endoscopic therapy first 1, 6
• Consider angiography when endoscopy fails to identify or control bleeding, particularly in patients with hemodynamic instability or transfusion requirement >5 units 2
• Perform transcatheter embolization during diagnostic angiography to achieve hemostasis when appropriate 2
• Consider surgery when hemodynamic instability persists despite aggressive resuscitation, blood transfusion requirement exceeds 6 units, or severe bleeding recurs despite non-surgical interventions 3, 2

Medication Management After Bleeding Control

• For patients on aspirin for primary prophylaxis, permanently discontinue; for secondary prevention, do not routinely stop or restart as soon as hemostasis is achieved 4
• For patients with low thrombotic risk on anticoagulants, consider restarting therapy approximately 7 days after hemorrhage cessation 2, 4
• Continue proton pump inhibitor therapy for secondary prophylaxis in patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 2

Common Pitfalls to Avoid

• Failing to consider an upper GI source in patients presenting with rectal bleeding and hemodynamic instability 2, 4
• Performing blind segmental resection or total abdominal colectomy without accurate preoperative localization of the bleeding site (associated with rebleeding rates up to 33% and mortality rates of 33-57%) 3
• Delaying resuscitation while waiting for diagnostic procedures 1, 2
• Overlooking the importance of early risk stratification, which guides appropriate triage and management decisions 1, 4