What is the management approach for gastrointestinal bleeding?

Management of Gastrointestinal Bleeding

Immediately assess hemodynamic stability using shock index (heart rate ÷ systolic blood pressure)—a value >1 indicates instability and dictates your entire management pathway. 1, 2, 3

Initial Resuscitation and Assessment

Establish large-bore IV access (two 18-gauge or larger) and begin crystalloid resuscitation immediately to restore blood pressure and heart rate. 2 Do not delay resuscitation for diagnostic testing.

• Check orthostatic vital signs in stable-appearing patients—orthostatic hypotension indicates significant blood loss requiring ICU admission. 1, 2
• Perform digital rectal examination to confirm blood in stool and exclude anorectal pathology. 1, 2, 3
• Correct coagulopathy immediately: transfuse fresh frozen plasma or prothrombin complex concentrate for INR >1.5, and platelets for platelet count <50,000/µL. 1, 2

Transfusion Strategy

Use restrictive transfusion thresholds based on cardiovascular status:

• For patients without cardiovascular disease: hemoglobin trigger 70 g/L with target 70-90 g/L. 1, 2, 3
• For patients with cardiovascular disease or active ischemia: hemoglobin trigger 80 g/L with target ≥100 g/L. 1, 2, 3

Management Algorithm Based on Hemodynamic Status

Hemodynamically Unstable Patients (Shock Index >1)

Perform CT angiography immediately—this is the fastest, least invasive method to localize active bleeding before any therapeutic intervention. 1, 2, 3 Do not proceed to colonoscopy in unstable patients.

• Following positive CTA, proceed directly to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology. 1, 2
• Consider upper endoscopy if no lower GI source is identified, as hemodynamic instability may indicate an upper GI source. 1, 2
• Surgery is reserved only for patients who fail angiographic intervention or continue to deteriorate despite aggressive resuscitation and all localization attempts. 1, 2

Hemodynamically Stable Patients with Lower GI Bleeding

Calculate the Oakland score (includes age, gender, previous LGIB admission, digital rectal examination findings, heart rate, systolic blood pressure, and hemoglobin level) to guide disposition. 1

• Oakland score ≤8 points: discharge for urgent outpatient investigation. 1
• Oakland score >8 points: admit to hospital for colonoscopy. 1

Upper GI Bleeding Management

Develop institution-specific protocols for multidisciplinary management with access to an endoscopist trained in endoscopic hemostasis. 4

• Administer intravenous proton pump inhibitors in the acute setting to decrease high-risk stigmata during endoscopy. 5, 6
• Consider erythromycin infusion 30-60 minutes before endoscopy to aid in diagnosis. 5, 7
• Perform endoscopy within 24 hours after initial stabilization, with earlier endoscopy for high-risk patients after resuscitation. 4, 6, 7
• Endoscopic therapy is indicated for ulcers with active spurting/oozing and nonbleeding visible vessels, using bipolar electrocoagulation, heater probe, clips, or hemostatic powder. 7
• After endoscopic hemostasis, administer high-dose proton pump inhibitor therapy continuously or intermittently for 3 days, followed by twice-daily oral therapy for 2 weeks. 7

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, 3

• 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

ICU Admission Criteria

Admit to ICU if any of the following are present: 1, 2

• 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: 4, 1, 2

• 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%. 2 Every effort must be made to localize bleeding through radiological and endoscopic modalities before surgery.

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, 3