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

Initial Management of Gastrointestinal Bleeding

For any patient presenting with GI bleeding, immediately calculate the shock index (heart rate ÷ systolic blood pressure)—a value >1 defines hemodynamic instability and mandates urgent CT angiography rather than routine endoscopy. 1

Immediate Hemodynamic Assessment and Resuscitation

Assess Stability

• Calculate shock index at presentation: heart rate divided by systolic blood pressure 1, 2
• Shock index >1 indicates instability requiring urgent intervention rather than standard endoscopic approach 1, 2
• Check for orthostatic hypotension, which indicates significant blood loss requiring ICU admission 3

Establish Vascular Access and Fluid Resuscitation

• Place at least two large-bore intravenous catheters to allow rapid volume expansion 1
• Initiate fluid resuscitation with crystalloids to restore and maintain hemodynamic stability 1

Blood Transfusion Strategy

Use restrictive transfusion thresholds for most patients: hemoglobin trigger of 70 g/L with target range 7-9 g/dL (70-90 g/L). 4, 1, 2

• For patients without cardiovascular disease: transfuse at hemoglobin <80 g/L 4
• For patients with cardiovascular disease: use higher threshold with hemoglobin trigger of 80 g/L and target ≥100 g/L 4, 1, 2

Correct Coagulopathy Immediately

• Transfuse fresh frozen plasma for INR >1.5 3
• Transfuse platelets for platelet count <50,000/µL 3

Diagnostic Approach Based on Hemodynamic Status

For Hemodynamically UNSTABLE Patients (Shock Index >1)

Perform CT angiography immediately to localize bleeding before any intervention—do NOT proceed directly to endoscopy. 1, 3, 2

The algorithm for unstable patients:

1. CT angiography first to rapidly localize the bleeding source 1, 3, 2
2. If CTA positive: proceed to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 3, 2
3. Always consider an upper GI source even with hematochezia, as hemodynamic instability may indicate upper GI bleeding 1, 2
4. If upper endoscopy is negative, perform CTA to evaluate for lower GI source 1
5. Surgery is reserved only for patients who remain unstable despite aggressive resuscitation AND after failure of angiographic intervention 3

For Hemodynamically STABLE Patients

Perform endoscopy within 24 hours of presentation. 4, 1

• For suspected upper GI bleeding: perform upper endoscopy within 24 hours 4, 1
• For suspected lower GI bleeding: calculate Oakland score to determine need for admission 1, 3
  • Oakland score ≤8: safe for discharge with urgent outpatient investigation 1, 3
  • Oakland score >8: requires hospital admission for colonoscopy 1, 3
• Perform colonoscopy within 24 hours after adequate bowel preparation for lower GI bleeding 1

Management of Anticoagulation and Antiplatelet Therapy

Warfarin Management

• Interrupt warfarin immediately at presentation for unstable GI hemorrhage 1, 3, 2
• Reverse anticoagulation with prothrombin complex concentrate and vitamin K 1, 3, 2
• For patients with low thrombotic risk: restart warfarin 7 days after hemorrhage 1, 3, 2
• For patients with high thrombotic risk: consider low molecular weight heparin therapy at 48 hours after hemorrhage 2

Direct Oral Anticoagulants (DOACs)

• Do not delay endoscopy (with or without endoscopic hemostatic therapy) in patients receiving DOACs 4

Aspirin Management

• For primary prophylaxis: permanently discontinue aspirin 3, 2
• For secondary prevention: do NOT routinely stop aspirin; if stopped, restart as soon as hemostasis is achieved 3, 2

Dual Antiplatelet Therapy

• If P2Y12 receptor antagonist is stopped, reinstate within 5 days to prevent thrombotic complications 2

Pharmacologic Therapy

Proton Pump Inhibitors (PPIs)

• Pre-endoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay endoscopy 4

Promotility Agents

• Promotility agents should NOT be used routinely before endoscopy to increase diagnostic yield 4

ICU Admission Criteria

Admit to ICU if any of the following are present: 3

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

Critical Pitfalls to Avoid

Failing to consider an upper GI source in patients with hemodynamic instability is a common and dangerous error. 1, 3, 2

• Do not delay endoscopy beyond 24 hours in high-risk patients 1
• Do not perform colonoscopy as the initial approach when shock index >1 or patient remains unstable after resuscitation 3
• Recognize that mortality in GI bleeding is generally related to comorbidity rather than exsanguination, with overall in-hospital mortality of 3.4% but rising to 18% for inpatient-onset bleeding and 20% for patients requiring ≥4 units of red cells 1, 3, 2
• Do not underestimate bleeding severity based solely on initial hemoglobin, as it may not reflect acute blood loss 1