What is the management approach for a patient presenting with gastrointestinal (GI) bleed?

Management of Gastrointestinal Bleeding

For any patient presenting with GI bleeding, immediately assess hemodynamic stability using shock index (heart rate ÷ systolic BP), with a shock index >1 indicating the need for urgent resuscitation and CT angiography before endoscopy. 1

Initial Assessment and Resuscitation

Hemodynamic Assessment:

• Calculate shock index at presentation—a value >1 defines instability and mandates urgent intervention rather than routine endoscopy 2, 1
• Place two large-bore IV catheters immediately to enable rapid volume expansion 1
• Initiate crystalloid resuscitation to restore hemodynamic stability 1

Risk Stratification:

• For upper GI bleeding, clinical predictors of poor outcome include: age >65 years, shock, comorbid illness, low hemoglobin, melena, fresh red blood in emesis/nasogastric aspirate, or on rectal exam 2
• For lower GI bleeding in stable patients, calculate the Oakland score (incorporating age, gender, prior LGIB, rectal exam findings, heart rate, systolic BP, and hemoglobin) 2, 3
  • Oakland score ≤8: Safe for immediate discharge with outpatient investigation 2, 3
  • Oakland score >8: Requires hospital admission 2, 3

Transfusion Strategy:

• Use restrictive threshold with hemoglobin trigger of 7 g/dL (target 7-9 g/dL) for most patients 1, 4
• Use higher threshold with hemoglobin trigger of 8 g/dL (target ≥10 g/dL) for patients with cardiovascular disease 1, 4

Diagnostic Approach Based on Hemodynamic Status

For Hemodynamically Unstable Patients (Shock Index >1):

Critical Pitfall to Avoid: Always consider an upper GI source in hemodynamically unstable patients, even if presenting with bright red blood per rectum—failure to do so leads to delayed diagnosis and increased mortality 1, 4

Diagnostic Algorithm:

1. Perform CT angiography immediately as the first diagnostic step—this provides the fastest, least invasive means to localize bleeding before any therapeutic intervention 1, 3, 4
2. Following positive CTA, proceed to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 3, 4
3. Do not perform colonoscopy as the initial approach when shock index >1 or patient remains unstable after resuscitation 3
4. Consider upper endoscopy if no lower GI source identified on CTA, as hemodynamic instability may indicate upper GI bleeding 3
5. Reserve surgery only for patients who fail angiographic intervention or continue deteriorating despite all localization attempts 3

For Hemodynamically Stable Patients:

Upper GI Bleeding:

• Perform upper endoscopy within 24 hours of presentation 1, 5, 6
• Consider nasogastric tube placement—presence of bright red blood predicts poor outcome and need for emergency endoscopy 2
• Administer proton pump inhibitors upon presentation 6, 7
• Consider erythromycin as prokinetic agent before endoscopy 6
• For cirrhotic patients, add antibiotics and vasoactive drugs before endoscopy 6

Lower GI Bleeding:

• Perform colonoscopy within 24 hours after adequate bowel preparation 2, 5
• Digital rectal examination is mandatory to confirm blood and exclude anorectal pathology 3, 4

Management of Anticoagulation and Antiplatelet Therapy

Warfarin Management:

• Immediately interrupt warfarin at presentation for unstable GI hemorrhage 1, 3, 4
• Reverse anticoagulation with prothrombin complex concentrate and vitamin K 1, 3, 4
• For low thrombotic risk: restart warfarin 7 days after hemorrhage 1, 3, 4
• For high thrombotic risk: consider low molecular weight heparin at 48 hours 4

Aspirin Management:

• For primary prophylaxis: permanently discontinue aspirin 3, 4
• For secondary prevention: do not routinely stop aspirin; if stopped, restart as soon as hemostasis achieved 3, 4, 5

Dual Antiplatelet Therapy:

• If P2Y12 receptor antagonist stopped, reinstate within 5 days to prevent thrombotic complications 4

Endoscopic Therapy

For High-Risk Stigmata:

• Provide endoscopic hemostasis for active bleeding, non-bleeding visible vessel, or adherent clot 5
• Modalities include mechanical therapy, thermal probes, injection therapy, or combination approaches 5
• For variceal bleeding: use ligation for esophageal varices and tissue glue for gastric varices 6

Post-Endoscopy Management:

• Administer high-dose proton pump inhibitors for 72 hours post-endoscopy in ulcer bleeding requiring endoscopic therapy—this is when rebleeding risk is highest 6, 7
• Continue antibiotics and vasoactive drugs for variceal bleeding 6

Management of Rebleeding

Recurrent Upper GI Bleeding:

• Attempt repeat endoscopic therapy first 6
• If endoscopy fails, proceed to transcatheter arterial embolization 6, 7
• Surgery reserved for failure of both endoscopic and radiologic interventions 6, 7

Recurrent Variceal Bleeding:

• Generally treated with transjugular intrahepatic portosystemic shunt 6

Recurrent Lower GI Bleeding:

• Consider repeat colonoscopy with endoscopic hemostasis if indicated 5

Critical Mortality Context

Mortality in GI bleeding is generally related to comorbidity rather than exsanguination, with overall in-hospital mortality of 3.4% for lower GI bleeding, but rising to 18% for inpatient-onset bleeding and 20% for patients requiring ≥4 units of red cells 3, 4. Upper GI bleeding carries 2-10% mortality 6.