How is anemia due to upper gastrointestinal bleeding (UGIB) managed?

Management of Anemia from Upper Gastrointestinal Bleeding

Blood Transfusion Strategy

Transfuse red blood cells when hemoglobin falls to 70 g/L or less in hemodynamically stable patients without cardiovascular disease. 1

Transfusion Thresholds by Patient Population

• Standard patients (no cardiac disease): Initiate transfusion at hemoglobin <70 g/L with a target of 70-90 g/L 1

• Patients with cardiovascular disease: Use a higher threshold of 60-100 g/L for transfusion initiation 1

  • This includes patients with ischemic heart disease, peripheral vascular disease, or heart failure 1
  • Hemoglobin levels below 82 g/L predict elevated cardiac troponin I levels, indicating myocardial injury 1, 2

• Hemodynamically unstable patients: Aggressive volume resuscitation takes priority, with transfusion thresholds adjusted based on ongoing bleeding and tissue hypoperfusion 1

Critical Considerations for Transfusion

• Avoid liberal transfusion strategies: Targeting hemoglobin 100-120 g/L is associated with higher mortality compared to 70-90 g/L in critically ill patients 1

• Transfusion risks: Blood transfusions carry risks of death, nosocomial infection, multiorgan dysfunction, and acute respiratory distress syndrome 1

• Hemoglobin measurement timing: Initial hemoglobin may not reflect true blood loss until equilibration occurs; ongoing or recurrent bleeding can cause rapid drops to dangerously low levels 1

Post-Discharge Anemia Management

Prescribe oral iron supplementation (600 mg/day ferrous fumarate for 6 weeks) for all patients discharged with anemia following nonvariceal UGIB. 3

Evidence for Oral Iron Supplementation

• Oral iron supplementation significantly improves hemoglobin response compared to no supplementation (72.7% vs 45.9% achieving composite hemoglobin response) 3

• Percentage change in hemoglobin at end of treatment is substantially higher with iron supplementation (34.2% vs 19.4%) 3

• Iron supplementation improves iron storage parameters, reducing the proportion of patients with ferritin <30 μg/L and transferrin saturation <16% 3

• No significant increase in adverse effects or reduction in adherence rates with iron supplementation 3

Discharge Hemoglobin Targets

• Discharge hemoglobin of 8-10 g/dL is acceptable in patients without cardiovascular disease or active bleeding 4
  • Associated with lower pRBC consumption and shorter hospital stays 4
  • Most patients recover from anemia within 45 days after discharge without critical complications 4
  • Rebleeding rates are not significantly different compared to discharge hemoglobin >10 g/dL 4

Follow-Up Protocol

Establish structured follow-up for all patients discharged with anemia, as current practice is inconsistent and inadequate. 5

Follow-Up Timeline

• 7 days post-discharge: Hemoglobin levels typically remain incompletely recovered 4

• 45 days post-discharge: Most patients show full hemoglobin recovery 4

• Monitor for rebleeding risk, which remains elevated in the early post-discharge period 4

Special Populations and Considerations

Patients on Anticoagulants

• Correct coagulopathy but do not delay endoscopy unless INR is supratherapeutic 1

• Intensive INR correction to <1.8 reduces mortality and myocardial infarctions 1, 2

Patients Requiring Antiplatelet Therapy

• Restart aspirin within 7 days when cardiovascular risks outweigh bleeding risks 2, 6

• For patients with coronary stents, restart P2Y12 inhibitor within 5 days to prevent stent thrombosis 6

• Continue aspirin if possible even during active bleeding for secondary prevention 6

Common Pitfalls to Avoid

• Over-transfusion: Targeting hemoglobin >100 g/L increases mortality without benefit 1

• Neglecting post-discharge anemia: Over 80% of patients are discharged with anemia, yet only 16% receive iron supplementation recommendations 5

• Inadequate follow-up: No standardized protocols exist for monitoring anemic patients after discharge 5

• Delaying endoscopy for coagulopathy correction: Mild to moderate coagulation defects (INR <2.5) do not require correction before endoscopy 1

• Ignoring cardiovascular risk: Elderly patients with UGIB often have cardiovascular comorbidities requiring higher transfusion thresholds and closer monitoring 1, 2