What is the initial management for a patient presenting with a significant gastrointestinal (GI) bleed?

Initial Management of Gastrointestinal Bleeding

Immediately assess hemodynamic stability using shock index (heart rate ÷ systolic blood pressure), with a value >1 defining instability that mandates urgent CT angiography rather than routine endoscopy. 1

Immediate Resuscitation

Vascular Access and Fluid Resuscitation

• Place at least two large-bore (18-gauge or larger) intravenous catheters in the antecubital fossae to allow rapid volume expansion 1, 2
• Initiate crystalloid fluid resuscitation immediately—most patients require 1-2 liters of saline solution 1, 2
• If shock persists after 2 liters, administer plasma expanders as ≥20% of blood volume has been lost 2

Blood Transfusion Strategy

• Use a restrictive transfusion threshold of hemoglobin <7 g/dL with target range 7-9 g/dL for most patients 1, 2
• For patients with cardiovascular disease (active ischemia, heart failure), use higher threshold of hemoglobin <8 g/dL with target ≥10 g/dL 1, 2

Airway Protection

• Intubate patients with massive hematemesis or altered mental status before endoscopy to protect the airway 2

Monitoring Requirements

• Insert urinary catheter and measure hourly urine output (goal >30 mL/hour) for severe bleeding 2
• Continuously monitor pulse and blood pressure with automated devices 2
• For patients with significant cardiac disease, measure central venous pressure (goal 5-10 cm H₂O) 2

Risk Stratification and Hemodynamic Assessment

Calculate Shock Index

• Shock index >1 (heart rate ÷ systolic BP) defines hemodynamic instability and changes the entire management algorithm 1, 2
• Additional high-risk features include: age >60 years, systolic BP <100 mmHg, heart rate >100 bpm, hemoglobin <8 g/dL 2

For Upper GI Bleeding (Hematemesis, Coffee-Ground Emesis, Melena)

• Use Glasgow Blatchford score ≤1 to identify very low-risk patients who can be discharged for outpatient endoscopy 2
• High-risk predictors include: bright red blood in nasogastric aspirate, fresh blood on rectal exam, significant comorbidities (renal insufficiency, liver disease, malignancy, heart disease) 2

For Lower GI Bleeding (Hematochezia)

• Calculate Oakland score (age, gender, prior LGIB, rectal exam findings, heart rate, systolic BP, hemoglobin) 3
• Oakland score ≤8: safe for outpatient investigation 3
• Oakland score >8: requires hospital admission 3

Management Algorithm Based on Hemodynamic Status

Hemodynamically UNSTABLE (Shock Index >1)

Step 1: Continue Aggressive Resuscitation

• Continue crystalloid resuscitation and restrictive transfusion strategy as above 1, 2
• Correct coagulopathy immediately: fresh frozen plasma for INR >1.5, platelets for count <50,000/µL 3

Step 2: Immediate CT Angiography

• Perform CT angiography immediately to localize bleeding before any endoscopic intervention 1, 2, 3
• CTA has 79-95% sensitivity and 95-100% specificity for active bleeding 2
• Do NOT proceed directly to colonoscopy in unstable patients 3

Step 3: Intervention Based on CTA Results

• If CTA positive: proceed to catheter angiography with embolization within 60 minutes 1, 3
• If CTA negative but upper GI source suspected: perform immediate upper endoscopy 2
• Always consider upper GI source in unstable patients even with bright red blood per rectum—failure to do so leads to delayed diagnosis and increased mortality 1, 2
• Surgery is reserved ONLY for patients who fail angiographic intervention or continue to deteriorate despite all localization attempts 3

Hemodynamically STABLE (Shock Index ≤1)

For Upper GI Bleeding

Step 1: Immediate Pharmacotherapy

• Start IV proton pump inhibitor immediately upon presentation (pantoprazole 80 mg IV bolus, then 8 mg/hour continuous infusion) 2
• If variceal bleeding suspected (cirrhosis, portal hypertension): start vasoactive drugs (terlipressin 2 mg IV every 4 hours OR octreotide 50 mcg/hour) AND antibiotics (ceftriaxone) before endoscopy 2

Step 2: Endoscopy Within 24 Hours

• Perform upper endoscopy within 24 hours after initial stabilization for all hospitalized patients 2
• Consider earlier endoscopy (within 12 hours) for high-risk patients: hemoglobin <8 g/dL, bright red blood in nasogastric aspirate, or significant comorbidities 2

Step 3: Endoscopic Therapy Based on Findings

• For high-risk stigmata (active bleeding, visible vessel, adherent clot): use combination therapy with epinephrine injection PLUS thermal coagulation or mechanical clips 2
• Never use epinephrine injection alone—it has suboptimal efficacy 2
• For adherent clots: irrigate to dislodge and treat underlying lesion 2
• No endoscopic therapy needed for clean-based ulcers or flat pigmented spots 2

Step 4: Post-Endoscopy Management

• Continue high-dose IV PPI (pantoprazole 8 mg/hour) for exactly 72 hours after successful endoscopic therapy for high-risk lesions 2
• After 72 hours: switch to oral PPI twice daily for 14 days, then once daily 2
• Test all patients for H. pylori and provide eradication therapy if positive—this reduces rebleeding rates 2

For Lower GI Bleeding

Step 1: Bowel Preparation

• Administer rapid bowel preparation (polyethylene glycol solution) 3, 4

Step 2: Colonoscopy Within 24 Hours

• Perform colonoscopy within 24 hours after adequate bowel preparation 3, 4

Step 3: Endoscopic Therapy

• For high-risk stigmata (active bleeding, visible vessel, adherent clot): use mechanical therapy (clips), thermal coagulation, or injection therapy based on lesion location and endoscopist experience 4

Management of Anticoagulation and Antiplatelet Therapy

Warfarin

• Interrupt warfarin immediately at presentation 1, 3
• For unstable hemorrhage: reverse with prothrombin complex concentrate AND vitamin K 1, 3
• Restart warfarin 7 days after hemorrhage for patients with low thrombotic risk 1, 3

Direct Oral Anticoagulants (DOACs)

• Interrupt DOAC immediately 3
• For life-threatening hemorrhage: administer specific reversal agents (idarucizumab for dabigatran, andexanet for anti-factor Xa inhibitors) 3
• Restart DOAC at maximum 7 days after hemorrhage 3

Aspirin

• For secondary cardiovascular prophylaxis: do NOT routinely stop aspirin; if stopped, restart as soon as hemostasis achieved (usually within 7 days) 2, 3
• For primary prophylaxis: permanently discontinue 3
• When restarting: use aspirin plus PPI rather than clopidogrel alone 2

Critical Pitfalls to Avoid

• Never assume hematochezia with hemodynamic instability is from a lower GI source—always consider upper GI bleeding, which has higher mortality 1, 2
• Do not perform colonoscopy as initial approach in unstable patients (shock index >1)—proceed to CTA first 3
• Do not use epinephrine injection alone for endoscopic hemostasis—always combine with thermal or mechanical therapy 2
• Do not delay endoscopy beyond 24 hours in hospitalized patients 2
• Recognize that mortality in GI bleeding is primarily related to comorbidities rather than exsanguination—overall mortality 3.4% but rises to 20% in patients requiring ≥4 units of blood 3
• Do not perform routine second-look endoscopy—it is not beneficial except in highly selected high-risk cases 2