What medications can be given to a patient presenting with hematochezia?

Medications for Hematochezia

Initial Resuscitation and Hemodynamic Support

For patients presenting with hematochezia, immediately initiate intravenous fluid resuscitation and blood product transfusion as needed to maintain hemoglobin >7 g/dL and mean arterial pressure >65 mmHg. 1

• Obtain complete blood count, coagulation studies (PT/INR, PTT), blood type and cross-match for potential transfusion 1
• Correct coagulopathy with appropriate blood products if present 1
• In patients on oral anticoagulants with major bleeding, administer reversal agents: vitamin K 5-10 mg IV for warfarin, idarucizumab for dabigatran, or andexanet alfa for apixaban/rivaroxaban 1, 2

Proton Pump Inhibitor Therapy

Administer high-dose intravenous omeprazole (80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours) if upper GI bleeding is suspected or confirmed, as this reduces rebleeding rates, transfusion requirements, and hospital stay. 1, 3

• Start PPI therapy immediately, even before endoscopy, as 14% of hematochezia cases originate from upper GI sources (most commonly duodenal ulcers) 1, 4
• The rationale is that pH >6 is necessary for platelet aggregation and clot stability, while clot lysis occurs when pH falls below 6 1, 3
• After 72-hour IV infusion, transition to oral PPI therapy for 6-8 weeks to allow mucosal healing 3
• H2 receptor antagonists are NOT recommended as they do not reliably increase gastric pH to 6 1

Vasoactive Medications for Variceal Bleeding

If anorectal varices or portal hypertension is suspected (based on history of cirrhosis), consider terlipressin or octreotide to reduce splanchnic blood flow and portal pressure. 1

• Terlipressin is the most evidence-based vasoactive agent for variceal bleeding 1
• Octreotide is an acceptable alternative with a better safety profile than vasopressin 1
• Temporarily suspend non-selective beta-blockers during acute bleeding episodes 1

Antibiotic Prophylaxis

Administer a short course of prophylactic antibiotics in patients with bleeding anorectal varices and underlying cirrhosis. 1

• This is a strong recommendation based on moderate quality evidence for reducing infection-related complications 1

Pre-Endoscopy Adjunctive Therapy

Administer erythromycin before endoscopy to enhance gastric visualization by promoting gastric emptying. 3

Medications to AVOID or DISCONTINUE

• Stop all antiplatelet agents (aspirin, clopidogrel) in patients with major bleeding 1
• Discontinue NSAIDs immediately as they are a common cause of peptic ulcer bleeding 1
• Do NOT use somatostatin routinely despite theoretical benefits, as evidence quality is insufficient 1
• Do NOT use tranexamic acid routinely, as further studies are needed despite some meta-analysis data suggesting benefit 1

Critical Clinical Pearls

• Never delay endoscopic intervention while relying solely on PPI therapy - medications complement but do not replace endoscopy 3
• Upper GI bleeding presenting as hematochezia carries worse prognosis with higher transfusion requirements (5.4 vs 4.0 units), increased need for surgery (11.7% vs 5.7%), and higher mortality (13.6% vs 7.5%) compared to melena presentation 4
• Cirrhosis independently predicts upper GI source of bleeding (OR 3.47) in hematochezia patients, with 30-day mortality of 17.5% versus 4.1% in non-cirrhotics 5