What are the guidelines for managing Upper Gastrointestinal Bleeding (UGIB) and Lower Gastrointestinal Bleeding (LGIB)?

Management of Upper and Lower Gastrointestinal Bleeding

UPPER GASTROINTESTINAL BLEEDING (UGIB)

Initial Resuscitation and Risk Stratification

Immediately assess hemodynamic status using shock index (heart rate ÷ systolic BP), with shock index >1 defining instability requiring urgent intervention rather than routine endoscopy. 1

• Place two large-bore IV catheters and initiate crystalloid resuscitation to restore hemodynamic stability 1, 2
• Transfuse red blood cells at hemoglobin <80 g/L (7-8 g/dL) for patients without cardiovascular disease; use higher threshold (≥80-100 g/L) for patients with cardiovascular disease 1, 2, 3
• Use Glasgow Blatchford score ≤1 to identify very-low-risk patients who can be discharged with outpatient follow-up without hospitalization or urgent endoscopy 1, 3
• High-risk features include: age >60 years, shock (HR >100 and SBP <100), hemoglobin <100 g/L, significant comorbidities (renal insufficiency, liver disease, heart failure), and bright red blood in emesis or nasogastric aspirate 1, 2

Pre-Endoscopic Pharmacological Management

Start intravenous proton pump inhibitors immediately upon presentation with an 80 mg IV bolus. 1

• Pre-endoscopic PPI may downstage endoscopic lesions and decrease need for intervention, but should not delay endoscopy 1
• For suspected variceal bleeding, initiate vasoactive drugs immediately (terlipressin 2 mg/4 hours for first 48 hours, then 1 mg/4 hours; or somatostatin 250 μg/hour continuous infusion with 250 μg bolus; or octreotide 50 μg/hour with 50 μg bolus) 1
• Administer antibiotic prophylaxis (ceftriaxone or norfloxacin) in cirrhotic patients with suspected variceal bleeding 1
• Consider erythromycin infusion before endoscopy as a prokinetic agent 4, 3
• Do NOT routinely use promotility agents before endoscopy 1

Endoscopic Management Timing and Approach

Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial stabilization. 1, 3

• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 1
• For hemodynamically unstable patients (shock index >1) who remain unstable after initial resuscitation, perform CT angiography immediately to localize bleeding before endoscopy (sensitivity 79-95%, specificity 95-100%) 1, 2
• If no source identified by CTA in unstable patients, perform immediate upper endoscopy 1
• Do NOT delay endoscopy in patients receiving anticoagulants (warfarin or DOACs)—proceed while correcting coagulopathy simultaneously 1, 5

Endoscopic Therapy Based on Lesion Characteristics

Use combination endoscopic therapy (epinephrine injection PLUS thermal coagulation or clips) for high-risk stigmata—NEVER use epinephrine injection alone. 1, 3

• High-risk stigmata requiring endoscopic therapy: active spurting or oozing, non-bleeding visible vessel, adherent clot 1, 3
• Recommended modalities: bipolar electrocoagulation, heater probe, through-the-scope clips, or sclerosant injection combined with epinephrine 1, 3
• For adherent clots, perform targeted irrigation to attempt dislodgement with appropriate treatment of underlying lesion 1
• TC-325 hemostatic powder is suggested as temporizing therapy for actively bleeding ulcers, but NOT as sole treatment 1, 3
• Over-the-scope clips show promise for recurrent ulcer bleeding after previous successful hemostasis 6, 3
• Do NOT perform endoscopic hemostatic therapy for low-risk stigmata (clean-based ulcer or flat pigmented spot) 1

Post-Endoscopic Pharmacological Management

Administer high-dose PPI therapy (80 mg IV bolus followed by 8 mg/hour continuous infusion) for exactly 72 hours in patients with high-risk stigmata who underwent successful endoscopic therapy. 1, 3

• After 72 hours, continue oral PPI twice daily for 14 days, then once daily for duration dependent on bleeding lesion nature 1
• For variceal bleeding, continue vasoactive drugs and antibiotics for 3-5 days 1
• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
• Routine second-look endoscopy is NOT recommended, though may be useful in selected high-risk patients 1

Management of Recurrent Bleeding

For recurrent bleeding after initial endoscopic therapy, perform repeat endoscopic therapy. 1, 3

• If repeat endoscopy fails, proceed to transcatheter embolization 3
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 1
• Surgery is reserved for patients who fail both endoscopic and radiological interventions 4, 7

Secondary Prevention and Antithrombotic Management

Restart aspirin when cardiovascular risks outweigh gastrointestinal risks (usually within 7 days). 1

• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding 1
• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 1
• For patients requiring NSAIDs, use PPI with COX-2 inhibitor to reduce rebleeding 1
• Test all patients for Helicobacter pylori and provide eradication therapy if positive—this reduces ulcer recurrence and rebleeding 1
• Testing during acute bleeding may have increased false-negative rates; confirmatory testing outside acute context may be necessary 1

Critical Pitfalls to Avoid in UGIB

• Always consider upper GI source in patients with hemodynamic instability, even when presenting with bright red blood per rectum—failure to do so leads to delayed diagnosis and treatment 1, 2
• Findings suggestive of upper GI source include: brisk rectal bleeding with hemodynamic compromise, history of peptic ulcer disease, portal hypertension, elevated blood urea/creatinine ratio, and antiplatelet drug use 8, 1
• Never use epinephrine injection alone—it provides suboptimal efficacy and must always be combined with thermal or mechanical therapy 1, 3
• Do NOT place nasogastric tube routinely in suspected UGIB—it does not reliably aid diagnosis, does not affect outcomes, and is complicated in up to one-third of patients 8

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LOWER GASTROINTESTINAL BLEEDING (LGIB)

Initial Assessment and Risk Stratification

Calculate shock index at presentation—a value >1 defines instability and mandates urgent intervention with CT angiography rather than colonoscopy. 8, 2

• Use Oakland score (incorporating age, gender, prior LGIB, rectal exam findings, heart rate, systolic BP, hemoglobin) to determine need for hospital admission: score ≤8 indicates safe discharge for outpatient investigation; score >8 requires admission 8, 2
• Resuscitate with crystalloids and transfuse at hemoglobin threshold <70-80 g/L 8, 9

Diagnostic Approach Based on Hemodynamic Status

For hemodynamically unstable patients (shock index ≥1), perform CT angiography as first-line investigation immediately to localize bleeding before any intervention. 8

• CTA is preferred over colonoscopy in unstable patients because it can localize bleeding in upper GI tract or small bowel, is widely available, can be rapidly accessed, and requires no bowel preparation 8
• CTA has sensitivity 79-95% and specificity 95-100% for detecting bleeding if velocity is 0.3-1.0 mL/min 8
• Always consider upper GI source in unstable patients with bright red rectal bleeding—perform upper endoscopy immediately if no source identified by CTA 8
• Bright red rectal bleeding may indicate anorectal source—perform direct anorectal inspection first 8

For hemodynamically stable patients, perform colonoscopy within 24 hours after adequate bowel preparation as the initial diagnostic procedure. 8, 9

• Colonoscopy should be performed after adequate colon preparation 8, 9
• No advantage with urgent colonoscopy (<12 hours) versus elective colonoscopy (36-60 hours) for diagnostic/therapeutic yield, length of stay, transfusion requirements, or cost in stable patients 8

Endoscopic Therapy for LGIB

Provide endoscopic hemostasis therapy to patients with high-risk endoscopic stigmata including active bleeding, non-bleeding visible vessel, or adherent clot. 9

• Modalities include mechanical therapy (clips), thermal coagulation, injection therapy, or combination—choice guided by bleeding etiology, access to bleeding site, and endoscopist experience 9
• Over-the-scope clips show high technical success (97.9%) and primary hemostasis rates (96.4%) for high-risk LGIB lesions 6

Management of Recurrent LGIB

For evidence of recurrent bleeding, consider repeat colonoscopy with endoscopic hemostasis if indicated. 9

• For high-risk patients with ongoing bleeding who do not respond to resuscitation and cannot tolerate bowel preparation, consider radiographic interventions (tagged RBC scintigraphy, CTA, or angiography) 9
• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes for hemodynamically unstable patients 2

Additional Investigations for Obscure Bleeding

If imaging, upper and lower endoscopy are inconclusive, consider nuclear medicine studies or video capsule endoscopy. 8, 2

• Nuclear medicine offers sensitivity 60-93% when other investigations are negative, particularly for intermittent or slow bleeding 8
• Video capsule endoscopy ideally within 48 hours has high diagnostic yield (87-91.9%) for obscure GI bleeding 2
• Double-balloon enteroscopy can be considered for direct visualization and intervention in small bowel 2
• Mesenteric angiography is unlikely to be beneficial in immediate setting, particularly in hemodynamically stable patients 8
• There is no evidence that repeat CTA is beneficial unless bleeding becomes more brisk 8

Secondary Prevention for LGIB

Avoid NSAID use in patients with history of acute LGIB, particularly if secondary to diverticulosis or angioectasia. 9

• Patients with established high-risk cardiovascular disease should NOT stop aspirin therapy (secondary prophylaxis) in setting of LGIB 9
• Timing of aspirin resumption depends on severity of bleeding, perceived adequacy of hemostasis, and risk of thromboembolic event 9

Critical Pitfalls to Avoid in LGIB

• Do NOT proceed directly to colonoscopy in hemodynamically unstable patients—CTA should be first-line investigation 8
• Always exclude upper GI source in patients with hemodynamic instability and hematochezia before assuming lower GI source 8, 2
• For suspected post-polypectomy bleeding, perform colonoscopy rather than CTA 2