What is the management plan for a gastrointestinal (GI) bleed due to mild gastritis?

Management of GI Bleeding from Mild Gastritis

For mild gastritis causing GI bleeding, initiate high-dose proton pump inhibitor (PPI) therapy immediately—either omeprazole 40 mg once daily or pantoprazole 40 mg once daily—combined with aggressive supportive care, withdrawal of gastric irritants (NSAIDs, alcohol), and correction of any coagulopathy. 1, 2, 3, 4

Initial Assessment and Hemodynamic Stabilization

Calculate the shock index (heart rate/systolic blood pressure) immediately upon presentation. 5

• Shock index >1 indicates hemodynamic instability and requires ICU admission with aggressive resuscitation 5
• Check for orthostatic hypotension, which confirms significant blood loss requiring ICU-level care 5, 6
• Perform digital rectal examination to confirm blood in stool and characterize the bleeding (melena vs. hematochezia) 5, 6

For hemodynamically stable patients, calculate the Oakland score (includes age, gender, previous GI bleeding, digital rectal findings, heart rate, systolic BP, hemoglobin). 5

• Oakland score ≤8: safe for urgent outpatient investigation 5
• Oakland score >8: requires hospital admission for endoscopy 5

Resuscitation Protocol

Initiate IV fluid resuscitation immediately with restrictive transfusion thresholds: 5, 6

• Maintain hemoglobin >7 g/dL (70 g/L) for patients without cardiovascular disease 5
• Maintain hemoglobin >8 g/dL (80 g/L) for patients with cardiovascular disease, with target of 10 g/dL (100 g/L) 5, 6
• Transfuse fresh frozen plasma if INR >1.5 5, 6, 7
• Transfuse platelets if platelet count <50,000/µL 5, 6, 7

Pharmacologic Management

Start high-dose PPI therapy immediately—this is the cornerstone of medical management for hemorrhagic gastritis: 7, 1, 2, 3, 4

PPI Dosing Options:

• Omeprazole 40 mg once daily (FDA-approved for active benign gastric ulcer) 1
• Pantoprazole 40 mg once daily (equivalent efficacy) 2
• Take before meals; antacids may be used concomitantly 1

After endoscopic evaluation (if performed), continue high-dose intravenous PPI for 72 hours (the period of highest rebleeding risk), then transition to oral PPI. 7

Withdrawal of Gastric Irritants:

Immediately discontinue all NSAIDs and alcohol—these are the most common precipitants of hemorrhagic gastritis. 3, 4

• For patients on aspirin for primary prophylaxis: permanently discontinue 5, 7
• For patients on aspirin for secondary cardiovascular prevention: do not routinely stop; if stopped, restart as soon as hemostasis is achieved (usually within 7 days) 5, 7
• Avoid all COX-2 selective inhibitors during active bleeding 7

Anticoagulation Management:

For patients on warfarin: 5, 7

• Interrupt warfarin immediately 5
• Reverse anticoagulation with prothrombin complex concentrate and vitamin K for unstable hemorrhage 5, 7
• For patients with low thrombotic risk, restart warfarin 7 days after hemorrhage 5

Diagnostic Approach

The diagnostic pathway depends critically on hemodynamic status: 5, 6

For Hemodynamically Unstable Patients (Shock Index >1):

Perform CT angiography (CTA) immediately—this provides the fastest, least invasive means to localize active bleeding. 5, 6

• CTA has a 94% positive rate in hemodynamically unstable patients with GI bleeding 5
• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes 5
• Do NOT perform colonoscopy as the initial approach when shock index >1—this is explicitly contraindicated 5

For Hemodynamically Stable Patients:

Perform upper endoscopy (esophagogastroduodenoscopy) to confirm gastritis and exclude other sources. 8, 5

• Endoscopy allows direct visualization of diffuse mucosal inflammation, erosions, and active bleeding sites characteristic of hemorrhagic gastritis 3, 4
• Approximately 10-15% of patients presenting with acute severe hematochezia have an upper GI source 8

ICU Admission Criteria

Admit to ICU if any of the following are present: 5, 6

• Orthostatic hypotension 5, 6
• Hematocrit decrease ≥6% 6
• Transfusion requirement >2 units packed red blood cells 6
• Continuous active bleeding 6
• Persistent hemodynamic instability despite aggressive resuscitation 6

Escalation of Care for Refractory Bleeding

Most patients with hemorrhagic gastritis from mild gastritis stop bleeding within hours to a few days with conservative management (blood transfusions, PPI therapy, withdrawal of irritants). 9

For Patients Who Continue to Bleed Despite Medical Management:

Consider endoscopic therapy for visualized bleeding sites, though this is more challenging in diffuse mucosal bleeding. 4, 9

If bleeding persists despite aggressive medical and endoscopic therapy: 5, 4, 9

• Angiographic embolization is the next step for localized bleeding 5
• Surgery is an option of last resort—vagotomy combined with subtotal gastrectomy offers the best protection against rebleeding, though mortality approaches 30% 9
• Proceed directly to surgery only if patient remains unstable despite aggressive resuscitation AND after failure of other localization/intervention methods 5

Critical Pitfalls to Avoid

Failure to withdraw NSAIDs and alcohol immediately will result in continued mucosal injury and persistent bleeding. 3, 4

Do not delay resuscitation to obtain imaging in unstable patients—stabilize first, then image. 5, 6

Mortality in GI bleeding relates more to comorbidities than exsanguination (3.4% overall, but 18% for inpatient-onset bleeding and 20% for patients requiring ≥4 units of blood). 5, 6

Avoid aggressive bowel preparation if patient is actively bleeding or hemodynamically unstable—this can worsen bleeding. 6

Most patients with mild gastritis have underlying predisposing conditions (alcohol abuse, portal hypertension, NSAID use, physiologic stress from critical illness)—address these underlying factors to prevent recurrence. 4