What is the initial management of an acute gastrointestinal (GI) bleed in the emergency department?

Acute GI Bleed Management in the Emergency Department

Immediately calculate the shock index (heart rate ÷ systolic blood pressure) upon presentation, as this single metric determines your entire diagnostic and therapeutic pathway: if shock index >1, proceed directly to CT angiography rather than endoscopy, while if shock index ≤1, proceed with risk stratification and standard endoscopic evaluation. 1, 2

Initial Hemodynamic Assessment and Resuscitation

• Place at least two large-bore IV catheters and initiate aggressive crystalloid resuscitation immediately to restore hemodynamic stability 2
• Calculate shock index (HR/systolic BP) as your primary hemodynamic assessment tool, with shock index >1 defining instability 1, 2, 3
• Perform digital rectal examination to confirm blood in stool and exclude anorectal pathology 1, 3
• Check for orthostatic hypotension, which indicates significant blood loss requiring ICU admission 1

Risk Stratification for Hemodynamically Stable Patients

For patients with shock index ≤1, calculate the Oakland score (incorporating age, gender, previous LGIB admission, digital rectal examination findings, heart rate, systolic blood pressure, and hemoglobin level) to guide disposition decisions. 1

• Oakland score ≤8 points: safe for discharge with urgent outpatient investigation 1
• Oakland score >8 points: admit to hospital for inpatient colonoscopy 1

Transfusion Strategy

Use restrictive transfusion thresholds as your default approach, as this improves mortality and quality of life compared to liberal transfusion strategies. 1, 2, 3

• For patients without cardiovascular disease: Hb trigger 70 g/L, target 70-90 g/L 1, 2, 3
• For patients with cardiovascular disease: Hb trigger 80 g/L, target ≥100 g/L 1, 2, 3

Management of Hemodynamically Unstable Patients (Shock Index >1)

CT angiography is your first-line diagnostic test for unstable patients—not endoscopy—as it provides the fastest and least invasive means to localize bleeding with 79-95% sensitivity and 95-100% specificity. 1, 2, 3

Diagnostic Algorithm for Unstable Patients:

1. Perform CT angiography immediately (detects bleeding at rates of 0.3-1.0 mL/min) 1, 2
2. If CTA positive: proceed to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 2, 3
3. If no lower GI source identified: consider upper endoscopy, as hemodynamic instability may indicate an upper GI source 1, 2
4. Surgery is reserved only for patients who fail angiographic intervention or continue to deteriorate despite all localization attempts 1, 2

Critical Pitfall to Avoid:

Never proceed directly to colonoscopy when shock index >1 or patient remains unstable after resuscitation—this delays definitive localization and treatment. 1 The British Society of Gastroenterology explicitly recommends against colonoscopy as the initial approach in unstable patients 1

Coagulopathy Correction

Correct coagulopathy immediately upon identification, as this directly impacts bleeding control and mortality. 1

• Transfuse fresh frozen plasma for INR >1.5 1
• Transfuse platelets for platelet count <50,000/µL 1

Anticoagulation Management

Warfarin:

• Interrupt warfarin immediately at presentation 2, 3
• For unstable hemorrhage: reverse with prothrombin complex concentrate AND vitamin K 4, 2, 3
• Restart warfarin at 7 days after hemorrhage for patients with low thrombotic risk 4, 3
• Consider low molecular weight heparin at 48 hours for patients with high thrombotic risk 3

Direct Oral Anticoagulants (DOACs):

• Interrupt DOAC therapy immediately at presentation 4
• For life-threatening hemorrhage: administer specific reversal agents (idarucizumab for dabigatran, andexanet for anti-factor Xa inhibitors) 4
• Restart DOAC at maximum 7 days after hemorrhage 4
• Note that vitamin K, FFP, and protamine sulfate are ineffective for DOAC reversal 4

Antiplatelet Management

The decision to stop antiplatelet therapy depends entirely on whether it is for primary versus secondary prevention. 2, 3

• Aspirin for primary prophylaxis: permanently discontinue 2, 3
• Aspirin for secondary prevention: do NOT routinely stop; if stopped, restart as soon as hemostasis is achieved 2, 3
• For dual antiplatelet therapy: if P2Y12 receptor antagonist is stopped, reinstate within 5 days to prevent thrombotic complications 3

ICU Admission Criteria

Admit to ICU if any of the following are present: 1

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

Timing of Endoscopy for Stable Patients

• Upper GI bleeding: perform upper endoscopy within 24 hours after adequate resuscitation 2
• Lower GI bleeding: perform colonoscopy within 24 hours after adequate bowel preparation (on next available list, not necessarily within 12 hours) 4, 2

Mortality Context and Prognostic Factors

Mortality in GI bleeding is generally related to comorbidity rather than exsanguination, with overall in-hospital mortality of 3.4%. 1, 2, 3 However, mortality rises dramatically to 18% for inpatient-onset lower GI bleeding and 20% for patients requiring ≥4 units of red blood cells 1, 2, 3

Clinical predictors of poor outcome include age >65 years, shock, comorbid illness, low hemoglobin, melena, and fresh red blood in emesis or on rectal examination 2

Organizational Requirements

All hospitals routinely admitting GI bleeding patients must have: 4

• A designated GI bleeding lead clinician responsible for integrated care pathways 4
• Access to 7/7 on-site colonoscopy with endoscopic therapy capabilities 4
• Access to 24/7 interventional radiology either on-site or via formalized referral pathway 4