From the Guidelines
Management of an active gastrointestinal (GI) bleed in a hemodynamically stable patient involves a systematic approach focusing on resuscitation, medication therapy, and definitive treatment, with the most recent guidelines from 2024 recommending esophagogastroduodenoscopy as the usual first-line diagnostic and therapeutic investigation 1. The initial management should include establishing two large-bore IV lines (18-gauge or larger) and administering crystalloid fluids to maintain hemodynamic stability. Laboratory tests including complete blood count, coagulation studies, comprehensive metabolic panel, and type and cross-match should be obtained promptly.
- For upper GI bleeds, proton pump inhibitor (PPI) therapy should be initiated with an IV bolus of 80 mg pantoprazole or esomeprazole followed by continuous infusion at 8 mg/hour for 72 hours, or high-dose oral PPI therapy (40 mg twice daily) 1.
- Endoscopy should be performed within 24 hours to identify and treat the bleeding source.
- Correction of coagulopathy is essential, with vitamin K 10 mg IV for warfarin reversal, prothrombin complex concentrate for direct oral anticoagulants, and platelet transfusion for thrombocytopenia (goal >50,000/μL).
- Blood transfusion should be considered for hemoglobin <7 g/dL (or <8 g/dL in patients with cardiovascular disease). The role of imaging for GI bleeding, as recommended by the American College of Gastroenterology (ACG) and Society of Abdominal Radiology (SAR) consensus in 2024, suggests that CT angiography (CTA) can be used to evaluate patients with overt GI bleeding, particularly in hemodynamically unstable patients, but for hemodynamically stable patients, endoscopy remains the first-line diagnostic and therapeutic investigation 1. In cases where the bleeding site is suspected to be below the ligament of Treitz, video capsule endoscopy may be considered as an alternative diagnostic modality 1. Overall, the management approach aims to control bleeding while identifying and addressing the underlying cause to prevent rebleeding, with a focus on minimizing morbidity, mortality, and improving quality of life.
From the Research
Management of Active GI Bleed in Hemodynamically Stable Patients
The management of active GI bleed in hemodynamically stable patients involves several key steps:
- Initial assessment: The European Society of Gastrointestinal Endoscopy (ESGE) recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include a history of co-morbidities and medications that promote bleeding, hemodynamic parameters, physical examination, and laboratory markers 2.
- Risk score: A risk score, such as the Oakland score, can be used to aid in clinician judgment and guide decision-making for patient discharge and outpatient investigation 2.
- Transfusion strategy: In hemodynamically stable patients with acute lower gastrointestinal bleeding, a restrictive red blood cell transfusion strategy is recommended, with a hemoglobin threshold of ≤7 g/dL prompting red blood cell transfusion 2.
- Medication management: The ESGE recommends withholding vitamin K antagonists and direct oral anticoagulants in patients with major lower gastrointestinal bleeding, and correcting coagulopathy according to the severity of bleeding and thrombotic risk 2.
- Endoscopy: Colonoscopy should be performed sometime during the hospital stay for patients with major acute lower gastrointestinal bleeding, although the timing of colonoscopy does not appear to influence patient outcomes 2.
- Proton pump inhibitors: Proton pump inhibitors (PPIs) may be used as medical therapy to reduce the rate of rebleeding in patients with nonvariceal upper GI bleed (NVGIB) 3, 4, 5.
- Monitoring: Patients with GI bleeds should be closely monitored for signs of hemodynamic instability, as even seemingly stable patients can become unstable at any time 6.