What is the treatment for gastrointestinal (GI) bleeding?

Management of Gastrointestinal Bleeding

The treatment of gastrointestinal bleeding requires immediate hemodynamic assessment and resuscitation, followed by endoscopic intervention within 24 hours for diagnosis and treatment, with specific therapeutic approaches based on the bleeding location and characteristics. 1, 2

Initial Assessment and Resuscitation

• Immediately evaluate hemodynamic status (checking for pallor, tachycardia, hypotension, and orthostatic changes) as the critical first step 1
• Establish large-bore intravenous access for fluid resuscitation with crystalloids (normal saline or lactated Ringer solution) to restore end-organ perfusion 1, 2
• Transfuse packed red blood cells when hemoglobin is less than 7 g/dL (70 g/L), with a higher threshold (9 g/dL) for patients with massive bleeding or significant cardiovascular disease 1, 2
• Correct coagulopathy or thrombocytopenia with fresh frozen plasma or platelets 1, 2

Risk Stratification

• Stratify patients using validated prognostic scales such as the Glasgow Blatchford score or Oakland score to identify low-risk patients suitable for outpatient management 2, 3
• Categorize bleeding as minor (resolves with conservative therapy), chronic intermittent, severe life-threatening with periods of stability, or continual active bleeding 2

Diagnostic Approach

Upper GI Bleeding

• Perform upper endoscopy within 24 hours of presentation for suspected upper GI bleeding 3, 2
• Consider earlier endoscopy for high-risk patients with hemodynamic instability 3, 4
• Administer proton pump inhibitors before endoscopy to potentially downstage lesions 3, 5
• Consider administering erythromycin as a prokinetic agent 30-60 minutes before endoscopy to improve visualization 4, 5

Lower GI Bleeding

• Perform colonoscopy after bowel preparation for suspected lower GI bleeding in stable patients 1, 3
• For hemodynamically unstable patients with suspected lower GI bleeding, proceed directly to CT angiography 3, 1

Therapeutic Management

Upper GI Bleeding (Non-variceal)

• Apply endoscopic hemostasis for high-risk lesions using combination therapy 3
• Use clips or thermocoagulation, alone or with epinephrine injection (epinephrine injection alone is not recommended) 3, 1
• Administer high-dose intravenous proton pump inhibitors for 72 hours after successful endoscopic therapy for high-risk lesions 3, 1
• Consider hemostatic powder as temporizing therapy (not as sole treatment) for actively bleeding ulcers 1

Upper GI Bleeding (Variceal)

• Use endoscopic band ligation for esophageal varices and tissue glue for gastric varices 5
• Continue antibiotics and vasoactive drugs after endoscopic therapy 5

Lower GI Bleeding

• Apply endoscopic therapy (injection, clips, or thermal methods) for diverticular bleeding or angiodysplasia 1, 3
• Consider transcatheter arterial embolization if endoscopic therapy fails or is not feasible 1, 3
• Interrupt direct oral anticoagulant therapy immediately and consider reversal agents for life-threatening hemorrhage 1

Management of Persistent or Recurrent Bleeding

• Consider repeat endoscopic therapy for recurrent ulcer bleeding 3, 5
• For patients with persistent bleeding despite endoscopic intervention, consider angiography with embolization, particularly in patients with hemodynamic instability or transfusion requirement of >5 units of blood 3, 1
• Consider surgery when hemodynamic instability persists despite aggressive resuscitation, blood transfusion requirement exceeds 6 units, or severe bleeding recurs despite non-surgical interventions 1

Post-Bleeding Management

• Hospitalize high-risk patients for at least 72 hours after endoscopic hemostasis 3
• Test for Helicobacter pylori infection and provide eradication therapy if present 3
• For patients requiring NSAIDs, use a proton pump inhibitor with a cyclooxygenase-2 inhibitor to reduce rebleeding 3
• Restart acetylsalicylic acid (ASA) for secondary cardiovascular prophylaxis as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days); ASA plus PPI therapy is preferred over clopidogrel alone 3, 1
• Consider restarting direct oral anticoagulants at a maximum of 7 days after hemorrhage cessation 1

Special Considerations

• Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended 3
• Localization of the bleeding source prior to surgery allows for targeted resection rather than total colectomy, reducing complications 1
• In children, consider age-specific causes such as anal fissures (most common in young children) and Meckel's diverticulum (can cause massive bleeding) 6