What is the best approach for managing a patient with severe gastrointestinal bleeding?

Medical Management of Severe Gastrointestinal Bleeding

Immediate Hemodynamic Assessment and Resuscitation

Calculate the shock index (heart rate ÷ systolic blood pressure) immediately—a value >1 indicates hemodynamic instability requiring aggressive intervention and fundamentally changes your management approach. 1, 2, 3

• Establish two large-bore IV lines (18-gauge or larger) and begin crystalloid resuscitation to restore blood pressure and heart rate 2
• Check orthostatic vital signs in stable-appearing patients, as orthostatic hypotension indicates significant blood loss requiring ICU admission 1, 2
• Perform digital rectal examination to confirm blood in stool and exclude anorectal pathology 1, 2, 3

Blood Product Transfusion Strategy

Use restrictive transfusion thresholds: maintain hemoglobin >70 g/L (7 g/dL) with target 70-90 g/L for hemodynamically stable patients without cardiovascular disease. 1, 2, 4

• For patients with cardiovascular disease or active ischemia, use hemoglobin trigger of 80 g/L (8 g/dL) with target ≥100 g/L 1, 2
• Correct coagulopathy immediately: transfuse prothrombin complex concentrate plus vitamin K for INR >1.5 in patients on warfarin with unstable hemorrhage 1, 2, 3
• Transfuse platelets for platelet count <50,000/µL 1, 2

Management Algorithm Based on Source and Hemodynamic Status

For Hemodynamically UNSTABLE Patients (Shock Index >1):

Perform CT angiography immediately—this is the fastest, least invasive method to localize active bleeding before any therapeutic intervention. 1, 2, 3

• Following positive CTA, proceed directly to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 2
• Do NOT perform colonoscopy as the initial approach when shock index >1 or patient remains unstable after resuscitation 1
• Consider upper endoscopy if no lower GI source identified, as hemodynamic instability may indicate an upper GI source 1, 2
• Surgery should only be considered after every effort at radiological and endoscopic localization has failed, or if patient continues to deteriorate despite aggressive resuscitation 1, 2

For Hemodynamically STABLE Patients with Upper GI Bleeding:

Administer intravenous proton pump inhibitor (PPI) therapy before endoscopy to downstage the lesion, and perform endoscopy within 24 hours. 5, 6, 4

• Consider erythromycin infusion (250 mg IV over 30 minutes) before endoscopy to improve visualization 6, 4
• For high-risk lesions (active spurting/oozing, non-bleeding visible vessel), perform endoscopic hemostasis using clips or thermocoagulation, alone or with epinephrine injection 5, 4
• Epinephrine injection alone is NOT recommended 5
• After successful endoscopic hemostasis, administer high-dose intravenous PPI therapy continuously or intermittently for 3 days, followed by twice-daily oral PPI for the first 2 weeks 5, 4

For Hemodynamically STABLE Patients with Lower GI Bleeding:

Calculate the Oakland score (includes age, gender, previous LGIB admission, digital rectal examination findings, heart rate, systolic blood pressure, and hemoglobin level) to guide disposition. 1, 3

• Patients with Oakland score ≤8 points can be safely discharged for urgent outpatient investigation 1, 3
• Patients with Oakland score >8 points should be admitted for colonoscopy within 24 hours after adequate bowel preparation 1, 3

Anticoagulation and Antiplatelet Management

For patients on warfarin with unstable hemorrhage, interrupt warfarin immediately and reverse with prothrombin complex concentrate plus vitamin K. 1, 2

• Restart warfarin at 7 days after hemorrhage in patients with low thrombotic risk 1, 2
• For patients on direct oral anticoagulants (DOACs), interrupt immediately; for life-threatening hemorrhage, administer specific reversal agents (idarucizumab for dabigatran, andexanet for anti-factor Xa inhibitors) 1
• Restart DOAC at maximum 7 days after hemorrhage 1
• Permanently discontinue aspirin if used for primary prophylaxis 1, 2
• Do NOT routinely stop aspirin for secondary cardiovascular prevention; if stopped, restart as soon as hemostasis is achieved 1, 2

ICU Admission Criteria

Admit to ICU if ANY of the following are present:

• Orthostatic hypotension 1, 2
• Hematocrit decrease ≥6% 1, 2
• Transfusion requirement >2 units packed red blood cells 1, 2
• Continuous active bleeding 1, 2
• Persistent hemodynamic instability despite aggressive resuscitation 1, 2

Management of Rebleeding

For recurrent upper GI bleeding after initial endoscopic hemostasis, perform repeat endoscopy; if endoscopic therapy fails, proceed to transcatheter embolization. 5, 4

• For recurrent lower GI bleeding after endoscopic intervention, consider angiographic embolization 1
• Surgery is indicated only when: hypotension and shock persist despite resuscitation, continued bleeding (>6 units transfused) without diagnosis despite all diagnostic modalities, or patient remains unstable despite all localization and intervention attempts 1, 2

Critical Pitfalls to Avoid

Blind segmental colonic resection without preoperative localization is associated with rebleeding rates as high as 33% and mortality of 33-57%—always attempt localization before surgery. 1, 2

• Emergency subtotal colectomy carries mortality rates of 27-33% and should be avoided unless all other options exhausted 1
• Failure to consider an upper GI source in hemodynamically unstable patients with presumed lower GI bleeding leads to delayed diagnosis—always perform upper endoscopy if lower GI workup is negative 1, 2
• Mortality in GI bleeding is primarily related to comorbidities rather than exsanguination: overall in-hospital mortality is 3.4%, but rises to 18% for inpatient-onset bleeding and 20% for patients requiring ≥4 units of red cells 1, 2, 3
• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 5