What is the management approach for gastrointestinal bleeding?

Management of Gastrointestinal Bleeding

Immediate Hemodynamic Assessment and Resuscitation

Calculate the shock index (heart rate ÷ systolic blood pressure) immediately upon presentation—a value >1 indicates hemodynamic instability requiring aggressive intervention and predicts poor outcomes. 1, 2

• Establish large-bore IV access (two 18-gauge or larger) and begin crystalloid resuscitation to restore blood pressure and heart rate 2
• Check orthostatic vital signs in stable-appearing patients, as orthostatic hypotension indicates significant blood loss requiring ICU admission 1, 3
• Perform digital rectal examination to confirm blood in stool, assess for melena, and exclude anorectal pathology 1, 3, 2

Blood Product Transfusion Strategy

Use restrictive transfusion thresholds: maintain hemoglobin >70 g/L (7 g/dL) with target 70-90 g/L for hemodynamically stable patients without cardiovascular disease. 1, 2

• For patients with cardiovascular disease or active ischemia, use hemoglobin trigger of 80 g/L (8 g/dL) with target ≥100 g/L 1, 3, 2
• Correct coagulopathy immediately: transfuse fresh frozen plasma or prothrombin complex concentrate for INR >1.5 1, 3, 2
• Transfuse platelets for platelet count <50,000/µL 3, 2

Risk Stratification and Disposition

For Lower GI Bleeding (Hemodynamically Stable)

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

• Oakland score ≤8 points: safe for urgent outpatient investigation 1
• Oakland score >8 points: requires hospital admission for colonoscopy 1

For Upper GI Bleeding (Hemodynamically Stable)

• Very-low-risk patients (Glasgow-Blatchford score = 0-1) may be discharged with outpatient follow-up 4

Management Algorithm Based on Hemodynamic Status

Hemodynamically Unstable Patients (Shock Index >1)

For hemodynamically unstable patients, perform CT angiography immediately—this provides the fastest, least invasive means to localize active bleeding before any therapeutic intervention. 1, 2

• Following positive CTA, proceed directly to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 2
• Do NOT perform colonoscopy as the initial approach when patients have shock index >1 or remain unstable after resuscitation 1
• Consider upper endoscopy if no lower GI source identified, as hemodynamic instability may indicate an upper GI source 1, 2
• Surgery should only be considered after every effort at radiological and endoscopic localization has failed, or if patient continues to deteriorate despite aggressive resuscitation 1, 2

Hemodynamically Stable Patients

For stable patients with suspected upper GI bleeding (hematemesis, coffee-ground emesis, melena), perform upper endoscopy within 24 hours after initial stabilization. 5, 4

• Administer intravenous proton pump inhibitors immediately to decrease probability of high-risk stigmata at endoscopy 5
• Give erythromycin infusion 30-60 minutes before endoscopy to aid visualization 6, 4
• Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels 4
• After endoscopic hemostasis, administer high-dose proton pump inhibitor therapy continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks 4

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

• 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, 6

ICU Admission Criteria

Admit to ICU if any of the following are present:

• Orthostatic hypotension 1, 3
• Hematocrit decrease ≥6% 3
• Transfusion requirement >2 units packed red blood cells 3
• Continuous active bleeding 3
• Persistent hemodynamic instability despite aggressive resuscitation 3

Surgical Indications

Surgery is indicated when:

• Hypotension and shock persist despite resuscitation 2
• Continued bleeding (>6 units of packed red blood cells transfused) without diagnosis despite emergency endoscopy and angiography 2
• Patient remains unstable despite aggressive resuscitation and all localization attempts have failed 1, 2

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
• 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
• Emergency subtotal colectomy carries mortality rates of 27-33% and should be avoided unless all other options exhausted 2

Institutional Preparedness

• Hospitals should develop institution-specific protocols for multidisciplinary management with access to an endoscopist trained in endoscopic hemostasis 7
• Support staff trained to assist in endoscopy should be available for urgent endoscopy 7