What is the relationship between Deep Vein Thrombosis (DVT) and upper Gastrointestinal (GI) bleeding?

From the Guidelines

For patients with both deep vein thrombosis (DVT) and upper gastrointestinal (GI) bleeding, the recommended approach is to temporarily pause anticoagulation therapy for the DVT until the GI bleeding is controlled, typically for 24-72 hours depending on bleeding severity. This approach is based on the need to balance the risks of thrombosis and bleeding, as untreated DVT can lead to pulmonary embolism, while continued anticoagulation during active bleeding can be life-threatening 1. The management of these patients involves several key steps:

• Temporarily pausing anticoagulation therapy for the DVT until the GI bleeding is controlled
• Using a lower-risk agent such as low molecular weight heparin (enoxaparin 1mg/kg twice daily or 1.5mg/kg once daily) before transitioning to oral anticoagulants once bleeding stabilizes
• Considering an inferior vena cava (IVC) filter as a temporary measure during the anticoagulation pause for patients at very high thrombotic risk
• Administering proton pump inhibitors (such as pantoprazole 40mg daily) to reduce rebleeding risk
• Identifying and treating the underlying cause of the GI bleeding through endoscopy
• Using a stepwise approach with close monitoring for recurrent bleeding when restarting anticoagulation This balanced approach is supported by guidelines and studies, including those from the American Society of Hematology 1, which emphasize the importance of careful management and regular reassessment of both thrombotic and bleeding risks throughout treatment. In the context of cancer-associated venous thromboembolism, the use of direct oral anticoagulants (DOACs) such as edoxaban and rivaroxaban may be considered, but with caution due to the higher risk of major bleeding, especially in patients with gastrointestinal cancer 1. Overall, the goal is to minimize the risk of both thrombotic and bleeding complications, while also considering the individual patient's risk factors and underlying conditions.

From the Research

DVT and Upper GI Bleeding

• The relationship between Deep Vein Thrombosis (DVT) and upper GI bleeding is complex, with limited direct evidence available 2, 3, 4.
• Upper GI bleeding is typically managed with endoscopy, proton pump inhibitors, and blood transfusions as needed 5, 6.
• Anticoagulation therapy, which is often used to prevent DVT, can increase the risk of GI bleeding 3, 4.
• The management of anticoagulation in patients with acute GI bleeding is challenging and requires consideration of the severity of bleeding, the intensity of anticoagulation, and the patient's thrombotic risk 3.

Risk Assessment and Management

• Risk assessment tools, such as the Glasgow-Blatchford score, can help identify patients with upper GI bleeding who are at low risk of adverse outcomes and may be discharged with outpatient follow-up 5, 6.
• Patients with hemodynamic instability and signs of upper GI bleeding should be offered urgent endoscopy, performed within 24 hours of presentation 6.
• The use of anticoagulation therapy in patients with upper GI bleeding should be carefully considered, with the decision to restart therapy depending on the individual patient's risk of thromboembolism and bleeding 4.

DVT Prophylaxis

• The timing of DVT prophylaxis in patients with upper GI bleeding is not well defined, but it is generally recommended to initiate prophylaxis after 24 hours of ICU admission 2.
• The use of subcutaneous heparin for DVT prophylaxis in patients with lower GI bleeding has been shown to increase transfusion requirements and length of stay in the ICU 2.