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

GI Bleed Workup and Management

Immediate Hemodynamic Assessment

Calculate the shock index (heart rate ÷ systolic blood pressure) immediately upon presentation—a shock index >1 defines hemodynamic instability and fundamentally changes your diagnostic approach. 1

• Place at least two large-bore intravenous catheters immediately 1, 2
• Initiate aggressive fluid resuscitation with crystalloids (normal saline or lactated Ringer solution) to restore hemodynamic stability 1, 2
• Check orthostatic vital signs if patient appears stable—orthostatic hypotension indicates significant blood loss requiring ICU admission 3

Critical Diagnostic Algorithm Based on Hemodynamic Status

For Hemodynamically UNSTABLE Patients (Shock Index >1):

Proceed directly to CT angiography as your first diagnostic step—NOT endoscopy. 1, 2

• CT angiography provides the fastest, least invasive means to localize bleeding with sensitivity 79-95% and specificity 95-100% for detecting active bleeding 1
• Following positive CT angiography, perform catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 2, 3
• Critical pitfall to avoid: Always consider an upper GI source even with hematochezia in unstable patients—failure to do so leads to delayed diagnosis and treatment 2, 3
• Reserve surgery only for patients who fail angiographic intervention or continue to deteriorate despite all localization attempts 1, 2

For Hemodynamically STABLE Patients:

Perform endoscopy within 24 hours after adequate resuscitation and bowel preparation. 1, 2

• Upper endoscopy for suspected upper GI bleeding (hematemesis, melena, coffee-ground emesis) 1, 4
• Colonoscopy for suspected lower GI bleeding after adequate bowel preparation 1, 5
• For lower GI bleeding, calculate the Oakland score (incorporating age, gender, prior LGIB, rectal exam findings, heart rate, systolic BP, hemoglobin) 2, 3
  • Oakland score ≤8: Safe for outpatient investigation 2, 3
  • Oakland score >8: Requires hospital admission 2, 3

Transfusion Strategy

Use restrictive transfusion thresholds for most patients. 1, 2

• Hemoglobin trigger of 70 g/L with target range 70-90 g/L for patients without cardiovascular disease 1, 2, 3
• Higher threshold for patients with cardiovascular disease: hemoglobin trigger 80 g/L with target ≥100 g/L 1, 2, 3

Essential Laboratory Workup

Obtain immediately upon presentation:

• Complete blood count (hemoglobin, hematocrit) to assess bleeding severity 2
• Coagulation studies (PT/INR, PTT) to evaluate for coagulopathy 2
• Basic metabolic panel 6
• Liver function tests (especially if variceal bleeding suspected) 2, 6
• Type and crossmatch for patients with severe bleeding or hemodynamic instability 2

Management of Anticoagulation and Antiplatelet Therapy

For warfarin: Interrupt immediately at presentation and reverse with prothrombin complex concentrate plus vitamin K for unstable bleeding 1, 2, 3

• Restart warfarin 7 days after hemorrhage in patients with low thrombotic risk 2, 3

For aspirin:

• Permanently discontinue if used for primary prophylaxis 1, 3
• Do NOT routinely stop if used for secondary prevention—restart as soon as hemostasis is achieved 1, 3, 5

Coagulopathy Correction

Correct coagulopathy immediately if present: 3

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

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

Clinical Predictors of Poor Outcome

High-risk features requiring more aggressive management: 1, 2

• Age >65 years
• Shock on presentation
• Comorbid illness
• Low hemoglobin
• Melena or fresh red blood in emesis/nasogastric aspirate or on rectal examination

Mortality Context

Mortality in GI bleeding is generally related to comorbidity rather than exsanguination. 1, 2, 3

• Overall in-hospital mortality: 3.4% 1
• Inpatient-onset lower GI bleeding: 18% mortality 1
• Patients requiring ≥4 units of red blood cells: 20% mortality 1, 3