What must be done before a Gastrointestinal (GI) consult to determine the source of bleeding?

From the Guidelines

Before a GI consult for source of bleeding, immediate evaluation and appropriate resuscitation are critical to proper management, and this should include obtaining vital signs, establishing IV access, and initiating volume resuscitation with crystalloids as needed 1.

Initial Assessment

The initial assessment should include:

• Obtaining vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation)
• Establishing IV access with at least two large-bore IVs (18-gauge or larger)
• Drawing blood for complete blood count, coagulation studies (PT/INR, PTT), comprehensive metabolic panel, and type and cross-match
• Reviewing medication history with particular attention to anticoagulants, antiplatelets, NSAIDs, and alcohol use, and holding these agents if possible

Resuscitation and Stabilization

Volume resuscitation should be initiated with crystalloids (normal saline or lactated Ringer's) at 1-2 liters initially for hemodynamically unstable patients 1.

Additional Measures

A focused physical examination should be performed, including digital rectal exam to assess for melena or hematochezia. For upper GI bleeding, a nasogastric tube may be placed to assess for active bleeding, as the presence of blood in nasogastric aspirate confirms an upper GI source and can have prognostic value 1. Patients should remain NPO (nothing by mouth) until endoscopy can be performed. For those with suspected variceal bleeding, consider starting octreotide at 50 mcg IV bolus followed by 50 mcg/hour infusion, and also consider liberalized octreotide infusions for patients with suspected or known liver disease 1. These steps are essential to stabilize the patient, assess the severity of bleeding, and provide the gastroenterologist with critical information to determine the timing and approach for endoscopic evaluation.

From the Research

Pre-GI Consult Preparation

Before a GI consult for the source of bleeding, several steps must be taken:

• Assessment of bleeding activity, severity, and hemodynamic compromise 2
• Differentiation between upper and lower gastrointestinal bleeding 2
• Initial supportive therapy, including:
  • Fluid resuscitation to reverse hypovolemia 3, 2
  • Blood transfusions to replete lost blood 4, 3, 2
  • Respiratory support as necessary 2
  • Proton pump inhibitor therapy to stabilize mucosal blood clots and promote hemostasis 3, 2
• Laboratory tests, such as:
  • Complete blood count 3
  • Basic metabolic panel 3
  • Coagulation panel 3
  • Liver tests 3
  • Type and crossmatch 3
• Clinical prediction guides, like the Glasgow-Blatchford bleeding score, for upper GI bleeding risk stratification and to determine therapy 3
• Consideration of urgent endoscopy for patients with hemodynamic instability and signs of upper GI bleeding, to be performed within 24 hours of presentation 3, 5