From the Guidelines
Management of upper or lower GI bleeding in the inpatient setting requires prompt assessment and intervention, with a focus on hemodynamic stabilization, endoscopic evaluation, and correction of coagulopathy, as outlined in the most recent guidelines 1.
Key Considerations
- For upper GI bleeding, initial management includes hemodynamic stabilization with IV fluids and blood products as needed, followed by proton pump inhibitor (PPI) therapy such as pantoprazole 80mg IV bolus then 8mg/hr continuous infusion for 72 hours, as recommended by recent guidelines 1.
- Urgent endoscopy within 24 hours is recommended to identify and treat the bleeding source, with endoscopic therapy including epinephrine injection, thermal coagulation, or clip placement for high-risk lesions.
- For lower GI bleeding, similar resuscitation measures apply, with colonoscopy performed within 24 hours after adequate bowel preparation, and CT angiography followed by interventional radiology embolization may be necessary for massive bleeding.
- Correction of coagulopathy is essential, with a target INR <1.5, and reversal agents should be used if the patient is on anticoagulants, as emphasized in the literature 1.
- Restrictive transfusion strategies, transfusing when Hgb <7 g/dL, or <8 g/dL in patients with cardiovascular disease, are preferred to reduce rebleeding and mortality, as supported by evidence 1.
Monitoring and Team Involvement
- Patients should be monitored in an appropriate setting with serial hemoglobin checks, vital sign monitoring, and assessment for rebleeding.
- Early involvement of gastroenterology, interventional radiology, and surgery teams is crucial for optimal outcomes, as mortality increases significantly with delayed intervention, particularly in elderly patients or those with significant comorbidities, as highlighted in the studies 1.
From the Research
Inpatient Admission for Upper GI or Lower GI Bleeding Management
- The management of acute gastrointestinal (GI) hemorrhage requires prompt diagnosis and multidisciplinary management to optimize clinical outcomes 2.
- Upper and lower GI tract sources have an extensive list of differential pathologies, and endoscopy remains the cornerstone for diagnostic and interventional purposes, significantly reducing the need for surgical procedures 2.
- For upper GI bleeding, common causes include peptic ulcer bleeding, gastritis, esophagitis, variceal bleeding, Mallory-Weiss syndrome, and cancer, and signs and symptoms may include abdominal pain, lightheadedness, dizziness, syncope, hematemesis, and melena 3.
- Laboratory tests for upper GI bleeding should include a complete blood count, basic metabolic panel, coagulation panel, liver tests, and type and crossmatch, and a bolus of normal saline or lactated Ringer solution should be rapidly infused to correct hypovolemia and to maintain blood pressure 3.
- Clinical prediction guides, such as the Glasgow-Blatchford bleeding score, are necessary for upper GI bleeding risk stratification and to determine therapy, and patients with hemodynamic instability and signs of upper GI bleeding should be offered urgent endoscopy, performed within 24 hours of presentation 3.
- Proton pump inhibitors (PPIs) should be initiated upon presentation with upper GI bleeding, and guidelines recommend high-dose PPI treatment for the first 72 hours post-endoscopy because this is when rebleeding risk is highest 4, 3, 5.
- For lower GI bleeding, management may necessitate additional imaging and interventions, including surgical management, and common bleeding disorders include colonic diverticular bleeding and angiodysplasias 2, 6.