What is the management approach for a patient presenting with severe gastrointestinal bleeding, potentially taking anticoagulants such as warfarin (anticoagulant) or aspirin (acetylsalicylic acid), and with suspected variceal bleeding?

Management of Severe Gastrointestinal Bleeding

Immediate Resuscitation and Hemodynamic Stabilization

Begin with immediate hemodynamic assessment and establish two large-bore IV lines for rapid fluid and blood product administration if the patient is hemodynamically unstable. 1

• Target mean arterial pressure >65 mmHg with crystalloid infusion while avoiding fluid overload 1
• Check vital signs immediately including heart rate, blood pressure, and assess for signs of hypovolemia or shock 1
• Use restrictive red blood cell transfusion thresholds: hemoglobin trigger of 70 g/L (target 70-90 g/L) for stable patients, or 80 g/L trigger (target 100 g/L) for those with cardiovascular disease 2
• Avoid over-transfusion as this may increase portal pressure and potentially worsen bleeding in patients with portal hypertension 1

Source Localization

Approximately 10-15% of patients with severe hematochezia have an upper GI source, so do not assume lower GI bleeding based on presentation alone. 1

• Even in patients with known diverticulosis presenting with hematochezia, up to 8% have an upper GI source 1
• In hemodynamically unstable patients with severe bleeding, strongly consider upper GI source first 1

Anticoagulation Management

Warfarin Management

For unstable gastrointestinal hemorrhage in patients on warfarin, reverse anticoagulation immediately with prothrombin complex concentrate and vitamin K. 2

• Simply discontinue warfarin for low-risk hemorrhage 2
• For severe hemorrhage requiring reversal, administer 5-25 mg (rarely up to 50 mg) parenteral vitamin K1 3
• In emergency situations with severe hemorrhage, give 200-500 mL fresh frozen plasma or commercial Factor IX complex 3
• Restart warfarin at 7 days after hemorrhage in patients with low thrombotic risk 2
• For high thrombotic risk patients (prosthetic metal mitral valve, AF with prosthetic valve or mitral stenosis, <3 months after venous thromboembolism), consider low molecular weight heparin at 48 hours after hemostasis 2

Direct Oral Anticoagulant (DOAC) Management

Interrupt DOAC therapy immediately at presentation. 2

• The anticoagulant effect is primarily managed by withholding the medication 2
• For life-threatening hemorrhage on DOACs, consider specific reversal agents such as idarucizumab (for dabigatran) or andexanet (for factor Xa inhibitors) 2
• Restart DOAC at a maximum of 7 days after hemorrhage 2

Antiplatelet Management

For aspirin used for secondary prevention, do not routinely stop it; if stopped, restart as soon as hemostasis is achieved. 2

• Aspirin for primary prophylaxis should be permanently discontinued 2
• For dual antiplatelet therapy with P2Y12 receptor antagonist and aspirin in patients with coronary stents, do not routinely stop; manage in liaison with cardiology 2
• In unstable hemorrhage requiring interruption of P2Y12 inhibitor, continue aspirin 2
• Reinstate P2Y12 receptor antagonist therapy within 5 days 2

Suspected Variceal Bleeding

In patients with portal hypertension presenting with GI bleeding, initiate vasoactive drugs (terlipressin or octreotide) immediately to reduce splanchnic blood flow and portal pressure. 1

• Start antibiotics immediately in suspected variceal bleeding 4
• Involve hepatology early for multidisciplinary management 1
• Consider transjugular intrahepatic portosystemic shunt (TIPS) for severe portal hypertension if not contraindicated 1
• Endoscopic variceal band ligation is the hemostatic treatment of choice for esophageal varices 5
• Use tissue glue for gastric varices 4
• Balloon tamponade can bridge to further therapy in torrential variceal hemorrhage when endoscopy fails 5

Endoscopic Intervention

Perform colonoscopy within 24 hours after hemodynamic stabilization for major lower GI bleeds. 1

• For upper GI bleeding, endoscopy should be performed within 24 hours after presentation 6, 4
• Administer erythromycin infusion before endoscopy to improve visualization 6
• Ensure adequate bowel preparation with polyethylene glycol solutions for lower GI bleeding 1
• Endoscopic hemostasis is the preferred first-line treatment for accessible bleeding sources 1
• For ulcers with active spurting/oozing or nonbleeding visible vessels, use at least two hemostatic modalities (bipolar electrocoagulation, heater probe, clips, or injection therapy) 6

Post-Endoscopic Management

After endoscopic hemostasis for peptic ulcer bleeding, administer high-dose proton pump inhibitor therapy continuously or intermittently for 3 days, followed by twice-daily oral PPI for the first 2 weeks. 6

• For recurrent bleeding, repeat endoscopy is suggested 6
• If endoscopic therapy fails, transcatheter embolization is the next step 6
• Surgery should be performed by colorectal surgeons capable of on-table colonoscopy, or in collaboration with medical endoscopists 2

Critical Pitfalls to Avoid

• Delaying resuscitation to perform diagnostic procedures—stabilization always takes priority 1
• Assuming lower GI source in severe bleeding without considering upper GI source 1
• Over-transfusion, which increases portal pressure and may worsen variceal bleeding 1
• Inadequate bowel preparation leading to poor visualization and missed diagnoses 1
• Premature resort to surgery before attempting radiological/endoscopic localization 1
• Stopping anticoagulation in high thrombotic risk patients without bridging therapy 2