What are the guidelines for monitoring gastrointestinal (GI) bleeding?

From the Guidelines

Monitoring a gastrointestinal (GI) bleed requires a comprehensive approach, including frequent vital sign checks, laboratory testing, and clinical assessment, with the goal of detecting rebleeding early and guiding resuscitation efforts, as recommended by the most recent guidelines 1.

Key Components of Monitoring

• Vital signs should be checked every 15-30 minutes initially, then every 1-2 hours once stabilized, focusing on heart rate, blood pressure, and orthostatic changes.
• Complete blood count should be obtained every 6-12 hours to track hemoglobin and hematocrit levels, with more frequent testing for active bleeding.
• Coagulation studies (PT/INR, PTT) should be monitored, especially if the patient is on anticoagulants.
• Serial physical exams should assess for abdominal tenderness, distension, and ongoing bleeding signs like melena or hematemesis.
• Continuous cardiac monitoring is recommended for high-risk patients.
• Fluid status should be tracked through intake/output measurements, daily weights, and BUN/creatinine levels.

Endoscopic Evaluation

• Endoscopic evaluation timing depends on bleeding severity—emergent for unstable patients with active bleeding, within 24 hours for most upper GI bleeds, and within 24-72 hours for lower GI bleeds, as supported by recent guidelines 1.
• The American College of Gastroenterology practice guidelines and an American Gastroenterological Association expert statement recommend esophagogastroduodenoscopy as the usual first-line diagnostic and therapeutic investigation 1.

Importance of Early Intervention

• Early risk stratification and intervention are crucial in managing GI bleeding, with the goal of reducing morbidity, mortality, and improving quality of life, as emphasized by the international consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding 1.
• The use of validated prognostic scales and early endoscopy can help identify high-risk patients and guide treatment decisions, as recommended by the guidelines 1.

From the Research

Monitoring of Gastrointestinal Bleeding

• The management of gastrointestinal bleeding requires a multidisciplinary approach, including resuscitation, endoscopic intervention, pharmacologic therapy, and sometimes surgical procedures 2.
• Goals of care aim to prevent end-organ injury, manage comorbid illnesses, identify the source of bleeding, stop continued bleeding, support oxygen carrying capacity, and prevent rebleeding 3.
• Clinical prediction guides, such as the Glasgow-Blatchford bleeding score, are necessary for upper GI bleeding risk stratification and to determine therapy 4.

Diagnostic and Therapeutic Approaches

• A bolus of normal saline or lactated Ringer solution should be rapidly infused to correct hypovolemia and to maintain blood pressure, and blood should be transfused when hemoglobin is less than 7 g per dL 4.
• Proton pump inhibitors should be initiated upon presentation with upper GI bleeding, with high-dose treatment recommended for the first 72 hours post-endoscopy 4.
• The use of intravenous bolus dosing of proton pump inhibitors, such as pantoprazole, may be an effective and cost-saving alternative to continuous infusion in hemodynamically stable patients 5.

Multidisciplinary Team Approach

• A multidisciplinary panel of physicians with expertise in Gastroenterology, Anesthesiology, and Transfusion Medicine can provide the best knowledge and guide clinical practitioners in the management of gastrointestinal bleeding 6.
• The approach to the patient with gastrointestinal bleeding can be complex and requires a personalized approach according to different clinical scenarios to improve outcomes 6.