What is the cause of gastrointestinal bleeding in a 52-year-old male with hematemesis and inability to ingest polyethylene glycol (PEG)?

From the Guidelines

I strongly recommend an urgent referral to a gastroenterologist for endoscopic evaluation due to the concerning symptoms of hematemesis (vomiting blood) and hematochezia (blood in stool), as the most recent evidence suggests that esophagogastroduodenoscopy is the usual first-line diagnostic and therapeutic investigation for nonvariceal upper gastrointestinal bleeding 1. While awaiting this consultation, the patient should be started on a proton pump inhibitor such as omeprazole 40mg twice daily or pantoprazole 40mg twice daily, as this can help reduce the risk of further bleeding. For the diagnostic colonoscopy preparation, instead of polyethylene glycol (PEG), consider alternative bowel preparation regimens such as sodium picosulfate/magnesium oxide/citric acid (Prepopik) or sodium sulfate/potassium sulfate/magnesium sulfate (Suprep), which have smaller volumes and may be better tolerated, especially since the patient reports vomiting when trying to ingest PEG. The patient should also be assessed for hemodynamic stability with vital signs and complete blood count to evaluate for significant blood loss. The presence of both upper and lower GI bleeding suggests potentially serious conditions including peptic ulcer disease, gastritis, esophageal varices, or malignancy, and therefore, anticoagulant and NSAID medications should be temporarily discontinued if possible. The patient should be instructed to go to the emergency department immediately if they experience dizziness, increased bleeding, severe abdominal pain, or signs of shock, as these can be signs of severe blood loss or other complications. It is also important to note that while 80% to 85% of cases of UGIB cease spontaneously, there is a high risk of rebleeding, massive hemorrhage, and death, and therefore, prompt medical attention is crucial 1. Key considerations in the management of this patient include:

• Aggressive volume resuscitation and maintenance of hemodynamic stability
• Identification and treatment of the source of hemorrhage
• Use of proton pump inhibitors to reduce the risk of further bleeding
• Alternative bowel preparation regimens for diagnostic colonoscopy
• Discontinuation of anticoagulant and NSAID medications if possible
• Close monitoring for signs of severe blood loss or other complications.

From the Research

Patient Assessment and Management

• The patient's symptoms of vomiting blood and the presence of blood in stool labs indicate a potential case of acute gastrointestinal bleeding, which requires prompt assessment and management 2, 3.
• The initial assessment should include a history of co-morbidities and medications that promote bleeding, hemodynamic parameters, physical examination, and laboratory markers 2.
• A risk score can be used to aid in clinician judgment, but should not replace it 2.

Diagnostic Approaches

• For patients with suspected upper gastrointestinal bleeding, endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk 4.
• In patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay 2.
• Computed tomography angiography can be used to locate the site of bleeding in patients with hemodynamic instability and suspected ongoing bleeding 2.

Treatment Strategies

• A restrictive red blood cell transfusion strategy can be used in hemodynamically stable patients with acute lower gastrointestinal bleeding, with a hemoglobin threshold of ≤7 g/dL prompting red blood cell transfusion 2.
• In patients with acute upper gastrointestinal bleeding, proton pump inhibitors and prokinetic agents can be administered, with antibiotics and vasoactive drugs recommended in patients with cirrhosis 4.
• Pre-endoscopy use of proton pump inhibitor intravenous bolus dosing can be considered in hemodynamically stable patients with suspected upper gastrointestinal bleeding 5.

Medication Management

• Vitamin K antagonists should be withheld in patients with major lower gastrointestinal bleeding, and coagulopathy should be corrected according to the severity of bleeding and thrombotic risk 2.
• Direct oral anticoagulants should be temporarily withheld at presentation in patients with major lower gastrointestinal bleeding 2.
• Aspirin should not be withheld in patients taking low-dose aspirin for secondary cardiovascular prevention, and should be resumed within 5 days if withheld 2.