What is the initial approach to managing a patient with a gastrointestinal (GI) bleed?

Initial Approach to Managing a Patient with Gastrointestinal Bleeding

Immediately assess hemodynamic stability using shock index (heart rate ÷ systolic blood pressure)—a value >1 indicates instability requiring urgent CT angiography and interventional radiology rather than routine endoscopy. 1, 2

Immediate Assessment Questions and Actions

Hemodynamic Status Assessment

• Calculate shock index at presentation (heart rate ÷ systolic BP): A value >1 defines instability and mandates urgent intervention rather than routine endoscopy 1, 2
• Check orthostatic vital signs in stable-appearing patients: Orthostatic hypotension indicates significant blood loss requiring ICU admission 1, 3
• Establish large-bore IV access (two 18-gauge or larger catheters) immediately to allow rapid volume expansion 1, 2

Critical History Questions

• Anticoagulation status: Ask specifically about warfarin, direct oral anticoagulants, aspirin, and P2Y12 inhibitors (clopidogrel, ticagrelor), as these require immediate management decisions 1, 3, 4
• Cardiovascular disease history: This determines transfusion thresholds (Hb trigger 7 g/dL vs 8 g/dL) 1, 3, 4
• Liver disease or portal hypertension: Consider octreotide infusion for suspected variceal bleeding 5
• Prior GI bleeding episodes: Increases risk and influences management urgency 3, 4
• Aspirin indication: Distinguish primary vs secondary cardiovascular prevention, as this determines whether to stop aspirin 3, 2, 4

Physical Examination Priorities

• Digital rectal examination: Mandatory to confirm blood in stool and exclude anorectal pathology 3, 2
• Nasogastric aspirate (in ventilated patients only): Bright red blood predicts poor outcome and need for emergency upper endoscopy; avoid in unsedated patients due to aspiration risk 5
• Volume of visualized blood loss: Document with photographs of emesis basins, bedsheets, or toilet bowls to guide remote-based decisions 5

Laboratory Assessment

• Complete blood count: Hemoglobin <70 g/L scores 22 points on risk stratification; hematocrit decrease ≥6% requires ICU admission 1, 3
• Coagulation studies: INR >1.5 requires immediate reversal with prothrombin complex concentrate 1, 3, 2
• Platelet count: <50,000/µL requires platelet transfusion 3, 2
• Blood type and cross-match: Essential for all patients with severe bleeding 1

Management Algorithm Based on Hemodynamic Status

For Hemodynamically UNSTABLE Patients (Shock Index >1)

Step 1: Resuscitation

• Initiate crystalloid resuscitation immediately to restore blood pressure and heart rate 1, 2
• Transfuse red blood cells using restrictive threshold: Hb trigger 70 g/L (target 70-90 g/L) for patients without cardiovascular disease 1, 3, 4
• Use higher transfusion threshold for cardiovascular disease: Hb trigger 80 g/L (target ≥100 g/L) 1, 3, 4
• Correct coagulopathy immediately: Fresh frozen plasma or prothrombin complex concentrate for INR >1.5; platelets for count <50,000/µL 3, 2

Step 2: Immediate Diagnostic Approach

• Perform CT angiography immediately—this provides the fastest, least invasive means to localize active bleeding before any therapeutic intervention 1, 3, 2
• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 3, 2
• Consider upper endoscopy if no lower GI source identified, as hemodynamic instability may indicate an upper GI source even with hematochezia 1, 3, 2

Step 3: Surgical Consultation

• Reserve surgery only for patients who fail angiographic intervention or continue to deteriorate despite all attempts at localization 3, 2
• Avoid blind segmental colonic resection: Associated with rebleeding rates of 33% and mortality of 33-57% 2

For Hemodynamically STABLE Patients

Step 1: Risk Stratification

• Calculate Oakland score (incorporates age, gender, prior LGIB, rectal exam findings, heart rate, systolic BP, hemoglobin): Score ≤8 indicates safe discharge for outpatient investigation; score >8 requires hospital admission 1, 3, 4
• For upper GI bleeding, assess clinical predictors: Age >65 years, shock, comorbid illness, low hemoglobin, melena, fresh red blood in emesis/nasogastric aspirate predict poor outcome 1

Step 2: Endoscopic Evaluation

• For suspected upper GI bleeding: Perform upper endoscopy within 24 hours of presentation 5, 1
• For suspected lower GI bleeding: Perform colonoscopy within 24 hours after adequate bowel preparation 5, 1, 4
• Defer endoscopy in patients with anemia without overt bleeding, small-volume bleeding, or self-limited bleeding 5

Anticoagulation and Antiplatelet Management

Warfarin Management

• Interrupt warfarin immediately for unstable GI hemorrhage 1, 3, 2
• Reverse with prothrombin complex concentrate plus vitamin K for unstable bleeding 1, 3, 2
• Restart warfarin at 7 days after hemorrhage in patients with low thrombotic risk 1, 3

Direct Oral Anticoagulant Management

• Temporarily withhold DOACs at presentation in patients with major bleeding 4

Aspirin Management

• Permanently discontinue aspirin if used for primary prophylaxis 3, 2
• Do NOT routinely stop aspirin for secondary cardiovascular prevention; if stopped, restart as soon as hemostasis is achieved 3, 2, 4

Dual Antiplatelet Therapy

• Continue aspirin in patients on dual antiplatelet therapy 4
• P2Y12 inhibitor can be continued or temporarily interrupted according to bleeding severity and ischemic risk; restart within 5 days if interrupted 4

ICU Admission Criteria

Admit to ICU if ANY of the following:

• Orthostatic hypotension 3, 2
• Hematocrit decrease ≥6% 3, 2
• Transfusion requirement >2 units packed red blood cells 3, 2
• Continuous active bleeding 3, 2
• Persistent hemodynamic instability despite aggressive resuscitation 3, 2

Pharmacologic Therapy

For Suspected Upper GI Bleeding

• Consider proton pump inhibitor infusions over intermittent IV administration 5
• Liberalized octreotide infusions for patients with suspected or known liver disease 5
• Scheduled antiemetics to prevent aspiration 5

For Coagulopathy Correction

• Platelets and/or clotting factors to correct iatrogenic or acquired coagulopathies 5
• Reversal agents if appropriate for specific anticoagulants 5

Critical Pitfalls to Avoid

• Failure to consider an upper GI source in hemodynamically unstable patients: Always perform upper endoscopy if lower GI workup is negative, as hemodynamic instability may indicate an upper GI source even with hematochezia 1, 3, 2
• Performing colonoscopy in unstable patients: Colonoscopy is explicitly contraindicated when shock index >1 or patient remains unstable after resuscitation 3, 2
• Underestimating mortality risk: Mortality 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 3, 2
• Blind surgical resection without localization: Emergency subtotal colectomy carries mortality rates of 27-33% and should be avoided unless all other options exhausted 2
• Nasogastric tube placement in unsedated patients: Risk of gagging, vomiting, and aerosolization; only perform in ventilated patients 5