What is the management of Gastrointestinal (GI) bleeding?

From the Guidelines

Management of gastrointestinal (GI) bleeding requires prompt assessment and intervention based on the severity and location of the bleed, with a focus on resuscitation, maintenance of hemodynamic stability, and triage, as outlined in the 2024 update of the ACR Appropriateness Criteria for Nonvariceal Upper Gastrointestinal Bleeding 1. For acute upper GI bleeding, immediate resuscitation with two large-bore IV lines for fluid replacement is essential, followed by blood transfusion if hemoglobin is below 7 g/dL (or 9 g/dL in patients with cardiovascular disease).

Key Interventions

• Administer intravenous proton pump inhibitors (PPI) such as pantoprazole 80 mg bolus followed by 8 mg/hour infusion for 72 hours after endoscopy confirms bleeding.
• Urgent endoscopy should be performed within 24 hours, with therapeutic intervention as needed, as recommended by the American College of Gastroenterology practice guidelines and an American Gastroenterological Association expert statement 1.
• For variceal bleeding, terlipressin 2 mg IV every 4 hours or octreotide 50 mcg bolus followed by 50 mcg/hour infusion should be started, along with prophylactic antibiotics (ceftriaxone 1g daily for 5-7 days).
• Lower GI bleeding management includes hemodynamic stabilization, colonoscopy preparation once stable, and intervention based on findings.

Additional Considerations

• Correction of coagulopathy is crucial in all cases, using vitamin K, fresh frozen plasma, or prothrombin complex concentrate as needed.
• Discontinue anticoagulants and antiplatelets if possible, but weigh the risk of thrombotic events.
• The underlying cause determines long-term management, which may include maintenance PPI therapy, beta-blockers for portal hypertension, or surgical intervention for certain conditions. The most recent and highest quality study, the 2024 update of the ACR Appropriateness Criteria for Nonvariceal Upper Gastrointestinal Bleeding 1, provides the basis for these recommendations, prioritizing morbidity, mortality, and quality of life as the primary outcomes.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

GI Bleed Management

• The management of gastrointestinal (GI) bleeding is a complex process that requires a multidisciplinary approach, including initial patient assessment, triage, resuscitation, specialist consultation, diagnostic evaluation, and medical therapy 2.
• Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%, and patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients 3.
• The management of severe UGIB requires prompt recognition and resuscitation, careful use of blood products, early correction of coagulopathy, and early endoscopic or radiologic interventions 4.

Diagnostic Evaluation and Risk Stratification

• Common risk factors for upper GI bleeding include prior upper GI bleeding, anticoagulant use, high-dose nonsteroidal anti-inflammatory drug use, and older age 5.
• Clinical prediction guides, such as the Glasgow-Blatchford bleeding score, are necessary for upper GI bleeding risk stratification and to determine therapy 5.
• Patients with hemodynamic instability and signs of upper GI bleeding should be offered urgent endoscopy, performed within 24 hours of presentation 3, 5.

Treatment and Management

• Proton pump inhibitors are the main pharmacologic intervention for UGIB, along with adequate resuscitation and timely endoscopic intervention 3, 4.
• Endoscopic therapy should be performed as soon as hemodynamic stabilization is achieved, and several radiologic interventions are now commonly used as a second-line intervention after endoscopy 4.
• A common strategy in patients with failed endoscopic hemostasis is to attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained 5.
• Guidelines recommend high-dose proton pump inhibitor treatment for the first 72 hours post-endoscopy because this is when rebleeding risk is highest 5.