What are the treatment options for gastrointestinal (GI) bleeding?

Treatment Options for Gastrointestinal Bleeding

Initial Resuscitation and Stabilization

Immediate hemodynamic assessment and aggressive resuscitation form the foundation of GI bleeding management, with large-bore IV access, restrictive transfusion thresholds, and coagulopathy correction taking priority before any diagnostic procedures. 1

• Establish two large-bore intravenous lines immediately for fluid resuscitation with normal saline or lactated Ringer solution 1
• Calculate shock index (heart rate/systolic BP) to assess hemodynamic stability, with shock index >1 indicating instability requiring immediate intervention 2
• Transfuse packed red blood cells using restrictive thresholds: maintain hemoglobin >7 g/dL for stable patients without cardiovascular disease, or >8-9 g/dL for patients with massive bleeding or significant cardiovascular disease 1, 2
• Correct coagulopathy immediately with fresh frozen plasma for INR >1.5 and platelets for platelet count <50,000/µL 1, 2

Upper GI Bleeding Management

Pre-Endoscopic Phase

High-dose intravenous proton pump inhibitor therapy should be initiated immediately upon presentation, before endoscopy, to reduce high-risk stigmata and improve endoscopic outcomes. 3, 1

• Administer IV proton pump inhibitor (omeprazole 80 mg bolus followed by 8 mg/hour infusion) before endoscopy 3, 4
• Give erythromycin 250 mg IV 30-60 minutes before endoscopy to improve visualization by promoting gastric emptying 5
• Perform upper endoscopy within 24 hours of presentation for stable patients, or emergently for hemodynamically unstable patients 3, 1

Endoscopic Therapy

Combination endoscopic therapy using epinephrine injection plus thermal coagulation or mechanical clips is superior to monotherapy and should be the standard approach for high-risk lesions. 3

• Use combination therapy (epinephrine injection plus thermal coagulation or clips) for actively bleeding ulcers or high-risk stigmata, as this is superior to either treatment alone 3
• Never use epinephrine injection as monotherapy—it must always be combined with another modality 3, 6
• Consider over-the-scope clips (OTSCs) or TC-325 hemostatic powder for refractory bleeding 5
• Reserve hemostatic powder as temporizing therapy only, not as sole definitive treatment 1

Post-Endoscopic Management

Continue high-dose IV proton pump inhibitor therapy for 72 hours after successful endoscopic hemostasis of high-risk peptic ulcer lesions. 3, 1

• Maintain IV PPI infusion (omeprazole 8 mg/hour or equivalent) for 3 days after successful endoscopic therapy 3, 1
• Routine second-look endoscopy is not recommended unless rebleeding is suspected 3
• Test all patients for Helicobacter pylori and provide eradication therapy if positive 3
• Start early enteral feeding for all upper GI bleeding patients 5

Lower GI Bleeding Management

Hemodynamically Stable Patients

For stable lower GI bleeding, colonoscopy after bowel preparation is the first-line diagnostic and therapeutic approach, with timing determined by Oakland score risk stratification. 1, 2

• Calculate Oakland score (incorporating age, gender, previous LGIB, rectal exam findings, vital signs, hemoglobin) to guide disposition 2
• Discharge patients with Oakland score ≤8 for urgent outpatient colonoscopy 2
• Admit patients with Oakland score >8 for inpatient colonoscopy after bowel preparation 1, 2
• Use endoscopic therapy including injection, clips, or thermal therapies for diverticular bleeding or angiodysplasia 1

Hemodynamically Unstable Patients

For hemodynamically unstable lower GI bleeding (shock index >1), proceed directly to CT angiography followed by transcatheter embolization—do not perform colonoscopy. 1, 2

• Perform CT angiography immediately as the first diagnostic step, as it provides the fastest and least invasive means to localize bleeding 1, 2
• Following positive CTA, perform catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 2
• Colonoscopy is explicitly contraindicated as the initial approach when shock index >1 or patients remain unstable after resuscitation 2
• Consider upper endoscopy if no lower source is identified, as hemodynamic instability may indicate an upper GI source 2

Angiographic Intervention

Transcatheter arterial embolization is the second-line therapy when endoscopic treatment fails or is not feasible, particularly for patients requiring >5 units of blood transfusion. 3, 1

• Angiography requires bleeding rate of at least 1 mL/min for accurate detection of contrast extravasation 3
• For stable patients with severe intermittent bleeding, perform technetium-99m red blood cell scanning first to screen for active bleeding, then proceed to urgent angiography within 1 hour if positive 3
• Intra-arterial vasopressin infusion controls hemorrhage in up to 91% of patients with diverticular disease or angiodysplasia, though bleeding recurs in 50% after cessation 3
• Transcatheter embolization provides more definitive hemostasis than vasopressin infusion 3, 1

Surgical Management

Surgery is indicated only when hemodynamic instability persists despite aggressive resuscitation, transfusion requirement exceeds 6 units, or severe bleeding recurs despite all non-surgical interventions. 1, 2

• Localize the bleeding source prior to surgery using CTA or angiography to allow targeted resection rather than total colectomy 1
• Diagnostic laparotomy is mandatory only in unstable patients not responding to resuscitation AND after failure of radiological and endoscopic localization methods 2
• Avoid laparotomy unless every effort has been made to localize bleeding through other modalities 2

Anticoagulation and Antiplatelet Management

Warfarin

Interrupt warfarin immediately at presentation and reverse with prothrombin complex concentrate plus vitamin K for unstable GI hemorrhage. 1, 2

• Administer four-factor prothrombin complex concentrate and vitamin K for life-threatening bleeding 1, 2
• Restart warfarin 7 days after hemorrhage cessation in patients with low thrombotic risk 2

Direct Oral Anticoagulants (DOACs)

Interrupt DOAC therapy immediately and consider specific reversal agents for life-threatening hemorrhage. 1

• Use idarucizumab for dabigatran reversal 7
• Use andexanet alfa for anti-factor Xa inhibitor (rivaroxaban, apixaban) reversal 7
• Restart DOAC therapy at maximum 7 days after hemorrhage cessation 1

Aspirin

Permanently discontinue aspirin used for primary prophylaxis; for secondary prevention, do not routinely stop aspirin, and if stopped, restart immediately once hemostasis is achieved. 2

Critical Pitfalls to Avoid

• Never perform colonoscopy first in hemodynamically unstable patients—this delays definitive therapy and increases mortality risk; proceed directly to CTA 2
• Never use epinephrine injection alone—it must be combined with thermal coagulation or mechanical clips to prevent rebleeding 3, 6
• Never skip risk stratification—failure to calculate shock index or Oakland score leads to inappropriate triage and delayed intervention 2
• Never assume old GI bleeding history (>7 days) is safe for procedures like thrombolysis—assess ongoing risk factors including peptic ulcer disease, anticoagulant use, or thrombocytopenia 7
• Never forget to test for H. pylori—failure to eradicate infection leads to ulcer recurrence 3
• Never perform routine second-look endoscopy—it does not improve outcomes and increases costs 3

Special Diagnostic Considerations

Small Bowel Evaluation

When upper endoscopy and colonoscopy are negative, proceed to video capsule endoscopy for complete small bowel visualization in stable patients. 3

• Video capsule endoscopy identifies the bleeding source in 55-65% of patients with obscure GI bleeding 3
• Push enteroscopy allows evaluation of the proximal 60 cm of jejunum if capsule endoscopy is unavailable 3