What is the management of acute gastrointestinal (GI) hemorrhage?

Management of Acute Gastrointestinal Hemorrhage

Immediate Hemodynamic Assessment and Resuscitation

For any patient with acute GI bleeding, immediately calculate the shock index (heart rate ÷ systolic blood pressure), and if >1, proceed directly to aggressive resuscitation followed by CT angiography rather than endoscopy. 1, 2

Initial Stabilization Steps

• Place at least two large-bore intravenous catheters to enable rapid volume expansion 2
• Initiate crystalloid fluid resuscitation immediately to restore hemodynamic stability 2
• Use restrictive transfusion thresholds: Hemoglobin trigger of 70 g/L with target range 70-90 g/L for patients without cardiovascular disease 1, 2
• For patients with cardiovascular disease: Use higher threshold with hemoglobin trigger of 80 g/L and target ≥100 g/L 1, 2

Critical pitfall: Over 80% of transfusions in lower GI bleeding may be inappropriate or unnecessary, so adhere strictly to these thresholds 1

Diagnostic Algorithm Based on Hemodynamic Status

For Hemodynamically Unstable Patients (Shock Index >1)

Perform CT angiography immediately as the first diagnostic test—do not proceed to colonoscopy or delay for bowel preparation. 1, 2

• CTA provides 79-95% sensitivity and 95-100% specificity for active bleeding at rates of 0.3-1.0 mL/min 1
• CTA is superior to colonoscopy in unstable patients because it can localize upper GI, small bowel, or lower GI sources without bowel preparation 1
• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 2, 3, 4

Always consider an upper GI source in hemodynamically unstable patients, even with bright red rectal bleeding, as this presentation can indicate UGIB 1, 2

• If CTA shows no source, perform upper endoscopy immediately before proceeding to colonoscopy 1
• Bright red rectal bleeding warrants direct anorectal inspection before other interventions 1

For Hemodynamically Stable Patients

Calculate the Oakland score (incorporating age, gender, previous LGIB, digital rectal exam findings, heart rate, systolic BP, and hemoglobin) to guide disposition 2, 4

• Oakland score ≤8: Safe for discharge with urgent outpatient investigation 2, 4
• Oakland score >8: Requires hospital admission for colonoscopy 4

For suspected upper GI bleeding in stable patients: Perform upper endoscopy within 24 hours of presentation 2

For suspected lower GI bleeding in stable patients: Perform colonoscopy after adequate bowel preparation 2

Critical evidence: One RCT comparing urgent (<12 hours) versus elective (36-60 hours) colonoscopy showed no advantage for urgent colonoscopy in diagnostic yield, therapeutic yield, length of stay, transfusion requirements, or cost 1

Management of Anticoagulation and Antiplatelet Therapy

Warfarin Management

Interrupt warfarin immediately at presentation in all patients with GI bleeding. 1, 3

• For unstable hemorrhage: Reverse with prothrombin complex concentrate and vitamin K 1, 3
• For patients with low thrombotic risk: Restart warfarin at exactly 7 days after hemorrhage—starting before this doubles rebleeding risk without reducing thromboembolism 1, 3, 4
• For patients with high thrombotic risk (prosthetic metal mitral valve, AF with prosthetic valve or mitral stenosis, <3 months after venous thromboembolism): Consider low molecular weight heparin at 48 hours after hemorrhage 1, 3

Direct Oral Anticoagulant (DOAC) Management

Interrupt DOAC therapy immediately at presentation. 1

• For life-threatening hemorrhage on DOACs: Consider reversal agents (idarucizumab for dabigatran, andexanet for factor Xa inhibitors) 1
• Restart DOAC therapy at maximum of 7 days after hemorrhage 1

Aspirin Management

The decision depends entirely on indication:

• Aspirin for primary prophylaxis: Permanently discontinue 1, 3, 4
• Aspirin for secondary prevention: Do not routinely stop; if stopped, restart as soon as hemostasis is achieved 1, 3, 4

Dual Antiplatelet Therapy (DAPT) Management

For patients with coronary stents on DAPT (aspirin + P2Y12 inhibitor):

• Do not routinely stop DAPT—manage in liaison with cardiology 1
• If unstable hemorrhage requires stopping P2Y12 inhibitor: Continue aspirin 1
• Reinstate P2Y12 inhibitor within 5 days to prevent thrombotic complications 1, 3, 4

Critical pitfall: A myocardial infarction from discontinuing antiplatelet therapy in a patient with coronary stents may be fatal, whereas most GI bleeding episodes cease spontaneously or respond to intervention 1

Surgical Intervention

No patient should proceed to emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities. 1, 4

• Surgery is reserved only for: Hemorrhagic shock non-responders to resuscitation after failure of angiographic and endoscopic localization attempts 2, 4

Essential Hospital Capabilities

All hospitals routinely admitting patients with GI bleeding must have:

• Access to 7-day on-site colonoscopy with endoscopic therapy capabilities 1
• Access to 24/7 interventional radiology either on-site or via formalized referral pathway 1
• A designated GI bleeding lead and agreed management pathways 1

Mortality Context and Risk Factors

Mortality in GI bleeding is generally related to comorbidity, not exsanguination. 1, 3, 4

• Overall in-hospital mortality: 3.4% 1, 3
• Mortality for inpatient-onset LGIB: 18% 1
• Mortality for patients requiring ≥4 units of red cells: 20% 1, 3

Common pitfall: Nasogastric tube placement in suspected UGIB is not routinely recommended—it does not reliably aid diagnosis, does not affect outcomes, and causes complications in up to one-third of patients 1