What are the management steps for an active gastrointestinal (GI) bleed?

Management of Active Gastrointestinal Bleeding

Immediate Hemodynamic Assessment and Resuscitation

Calculate the shock index (heart rate ÷ systolic blood pressure) immediately upon presentation—a value >1 indicates hemodynamic instability and mandates aggressive intervention. 1, 2

• Initiate large-bore IV access (two 18-gauge or larger) and begin crystalloid resuscitation to restore blood pressure and heart rate 2
• Check orthostatic vital signs in stable-appearing patients, as orthostatic hypotension indicates significant blood loss requiring ICU admission 1
• Perform digital rectal examination to confirm blood in stool and exclude anorectal pathology 1, 2

Blood Product Transfusion Strategy

Use restrictive transfusion thresholds: maintain hemoglobin >70 g/L (7 g/dL) with target 70-90 g/L for hemodynamically stable patients without cardiovascular disease. 1, 2

• For patients with cardiovascular disease or active ischemia, use hemoglobin trigger of 80 g/L (8 g/dL) with target ≥100 g/L 1, 2
• Correct coagulopathy immediately: transfuse fresh frozen plasma or prothrombin complex concentrate for INR >1.5 1, 2
• Transfuse platelets for platelet count <50,000/µL 1, 2

Management Algorithm Based on Hemodynamic Status

For Hemodynamically UNSTABLE Patients (Shock Index >1):

Perform CT angiography immediately—this provides the fastest, least invasive means to localize active bleeding before any therapeutic intervention. 1, 2

• Following positive CTA, proceed directly to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 2
• Do NOT perform colonoscopy as the initial approach when shock index >1 or patient remains unstable after resuscitation 1
• Consider upper endoscopy if no lower GI source identified, as hemodynamic instability may indicate an upper GI source 1, 2
• Surgery should only be considered after every effort at radiological and endoscopic localization has failed, or if patient continues to deteriorate despite aggressive resuscitation 1, 2

For Hemodynamically STABLE Patients:

Calculate the Oakland score (age, gender, previous LGIB admission, digital rectal findings, heart rate, systolic BP, hemoglobin) to determine disposition. 1, 2

• Oakland score ≤8 points: safe for discharge with urgent outpatient colonoscopy 1, 2
• Oakland score >8 points: admit for inpatient colonoscopy within 24 hours after adequate bowel preparation 1, 3
• For suspected upper GI bleeding (melena, hematemesis), perform upper endoscopy first 2, 4

Anticoagulation and Antiplatelet Management

For patients on warfarin with unstable hemorrhage, interrupt warfarin immediately and reverse with prothrombin complex concentrate plus vitamin K. 1, 2

• Restart warfarin at 7 days after hemorrhage in patients with low thrombotic risk 1, 2
• Permanently discontinue aspirin if used for primary prophylaxis 1, 2
• Do NOT routinely stop aspirin for secondary cardiovascular prevention; if stopped, restart as soon as hemostasis is achieved 1, 2, 3

ICU Admission Criteria

Admit to ICU if any of the following are present: 1

• Orthostatic hypotension
• Hematocrit decrease ≥6%
• Transfusion requirement >2 units packed red blood cells
• Continuous active bleeding
• Persistent hemodynamic instability despite aggressive resuscitation

Surgical Indications

Surgery is indicated when: 5, 1

• Hypotension and shock persist despite resuscitation
• Continued bleeding (>6 units of packed red blood cells transfused) without diagnosis despite emergency colonoscopy, angiography, and other modalities
• Patient remains unstable despite aggressive resuscitation and all localization attempts have failed

Critical Pitfalls to Avoid

Failure to consider an upper GI source in hemodynamically unstable patients leads to delayed diagnosis—always perform upper endoscopy if lower GI workup is negative. 1, 2

• Blind segmental colonic resection without preoperative localization is associated with rebleeding rates as high as 33% and mortality of 33-57% 5
• Mortality in GI bleeding is primarily related to comorbidities rather than exsanguination: overall in-hospital mortality is 3.4%, but rises to 18% for inpatient-onset bleeding and 20% for patients requiring ≥4 units of red cells 1, 2
• Emergency subtotal colectomy carries mortality rates of 27-33% and should be avoided unless all other options exhausted 5