What are the current guidelines for managing acute upper and lower gastrointestinal bleeding in adults?

Management of Acute Upper and Lower Gastrointestinal Bleeding

Initial Hemodynamic Assessment and Resuscitation

Calculate the shock index (heart rate ÷ systolic blood pressure) immediately upon presentation; a value >1 defines hemodynamic instability and mandates urgent CT angiography rather than endoscopy. 1

Resuscitation Protocol

• Place at least two large-bore intravenous catheters and initiate aggressive crystalloid resuscitation (normal saline or Ringer's lactate) to restore blood pressure and heart rate before any diagnostic procedure 2, 1
• Use restrictive transfusion thresholds: hemoglobin trigger of 70 g/L (target 70-90 g/L) for patients without cardiovascular disease 2, 1
• For patients with cardiovascular disease, use hemoglobin trigger of 80 g/L (target ≥100 g/L) 2, 1
• Correct coagulopathy immediately: transfuse fresh frozen plasma when INR >1.5 and platelets when count <50 × 10⁹/L 1, 3

Upper Gastrointestinal Bleeding Management

Risk Stratification

• Use the Glasgow-Blatchford score in the emergency department; patients with score 0-1 can be safely discharged with outpatient follow-up 4
• Post-endoscopy, apply the Rockall score to predict rebleeding risk and mortality 5

Pharmacologic Management

• Administer intravenous erythromycin (250 mg) 30-60 minutes before endoscopy to increase diagnostic yield at first examination 4, 6
• Pre-endoscopic proton pump inhibitor therapy may decrease the need for endoscopic intervention but does not improve mortality or rebleeding rates 6, 5
• After successful endoscopic hemostasis, give high-dose PPI therapy (80 mg bolus followed by 8 mg/hour continuous infusion) for 72 hours, then switch to oral PPI twice daily for 2 weeks 4, 6

Endoscopic Timing and Therapy

• Perform upper endoscopy within 24 hours of presentation for hospitalized patients 4, 2
• For ulcers with active spurting/oozing or non-bleeding visible vessels, provide endoscopic therapy using at least two hemostatic modalities (e.g., bipolar electrocoagulation plus epinephrine injection, or heater probe plus clips) 4, 6
• Ulcers with adherent clots may receive endoscopic therapy; flat spots or clean-based ulcers do not require endoscopic intervention 6

Management of Rebleeding

• If bleeding recurs after initial endoscopic therapy, perform a second endoscopic treatment 4, 6
• If endoscopic therapy fails twice, proceed to transcatheter arterial embolization rather than immediate surgery 4

Prevention of Recurrent Bleeding

• Eradicate H. pylori and document cure; after eradication, long-term PPI therapy is generally not needed 6
• For patients requiring aspirin for secondary cardiovascular prevention, restart aspirin within 1-7 days (ideally 1-3 days) after hemostasis is achieved, along with PPI therapy 6, 3
• Permanently discontinue NSAIDs; if they must be resumed, use low-dose COX-2-selective NSAID plus PPI 6

Variceal Bleeding

• Administer antibiotics (e.g., ceftriaxone) and vasopressin analogues (octreotide or terlipressin) immediately when variceal bleeding is suspected 5
• Endoscopic variceal band ligation is the hemostatic treatment of choice 5
• Balloon tamponade serves as a bridge to definitive therapy when endoscopy fails or in torrential hemorrhage 5

Lower Gastrointestinal Bleeding Management

Hemodynamically Unstable Patients (Shock Index >1)

For unstable patients, CT angiography is the mandatory first diagnostic test—NOT colonoscopy—because CTA provides rapid localization without bowel preparation and has 94% sensitivity for detecting bleeding as low as 0.3 mL/min. 1, 3

Diagnostic and Therapeutic Algorithm

1. Perform arterial-phase CT angiography immediately (avoid delayed phases and oral contrast, which mask extravasation) 1
2. If CTA identifies a bleeding source, proceed to catheter angiography with embolization within 60 minutes; embolization achieves hemostasis in 40-100% of cases 1, 3
3. If CTA shows no lower GI source, perform urgent upper endoscopy because 10-15% of severe hematochezia originates from the upper GI tract 1, 3
4. Colonoscopy is explicitly contraindicated when shock index >1 because it requires 4-6 L polyethylene glycol preparation over 3-4 hours, sedation that worsens shock, and does not address massive bleeding 1, 3

Surgical Intervention (Last Resort Only)

• Surgery is reserved exclusively for patients who fail angiographic embolization or continue to deteriorate despite maximal resuscitation and endovascular attempts 1, 3
• Blind segmental resection or emergency subtotal colectomy without prior localization carries rebleeding rates up to 33% and mortality 33-57%; emergency total colectomy mortality is 27-33% 1, 3

Hemodynamically Stable Patients (Shock Index ≤1)

Risk Stratification with Oakland Score

Calculate the Oakland score using: age, gender, previous LGIB admission, digital rectal examination findings, heart rate, systolic blood pressure, and hemoglobin level. 1, 7

• Oakland score ≤8: Discharge for urgent outpatient colonoscopy within 2 weeks (6% have underlying colorectal cancer) 1, 7
• Oakland score >8: Admit for inpatient colonoscopy on the next available list 1, 7

Colonoscopy Timing and Preparation

• Schedule colonoscopy on the next available inpatient list; urgent colonoscopy within 24 hours does NOT improve rebleeding, mortality, or length of stay compared with elective timing 1, 3
• Provide adequate bowel preparation with 4-6 L polyethylene glycol over 3-4 hours; inadequate preparation leads to 70% repeat-procedure rates and missed lesions 1, 3
• Perform digital rectal examination or proctoscopy first, as anorectal pathology accounts for 16.7% of diagnoses 1

Endoscopic Therapy for Specific Lesions

• Diverticular bleeding with visible vessels or adherent clots: Apply endoscopic hemostasis (clips, thermal therapy, or epinephrine injection) 1
• Post-polypectomy bleeding: Use loop/band ligation, epinephrine plus thermal therapy, or endoscopic clipping; delayed bleeding (up to 15 days) resolves spontaneously in >70% of cases 1, 3
• Colonic angiodysplasia: Inject 1:10,000 epinephrine before bipolar or heater-probe coagulation; use caution in cecal lesions to avoid perforation 1
• Radiation proctitis: Apply heater-probe or bipolar electrocoagulation, both equally effective at reducing severe bleeding 1

Anticoagulation and Antiplatelet Management

Warfarin

• Interrupt warfarin immediately at presentation 3, 1
• For unstable hemorrhage, reverse with 4-factor prothrombin complex concentrate PLUS low-dose vitamin K (<5 mg); do NOT use fresh frozen plasma as first-line therapy 3, 1
• Restart warfarin at 7 days after hemostasis for low thrombotic risk; restart at 3 days for high thrombotic risk (e.g., mechanical mitral valve, recent VTE <3 months) 3, 1
• For high-risk patients, consider bridging with low-molecular-weight heparin starting 48 hours after hemostasis 3

Direct Oral Anticoagulants (DOACs)

• Interrupt DOAC therapy immediately at presentation 3, 1
• For life-threatening hemorrhage, administer specific reversal agents: idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors 3, 1
• Restart DOAC at maximum 7 days after hemostasis 3, 1

Aspirin

• Aspirin for primary prophylaxis should be permanently discontinued 3, 1
• Aspirin for secondary cardiovascular prevention should NOT be routinely stopped; if stopped, restart as soon as hemostasis is achieved (ideally within 1-3 days, maximum 7 days) 3, 1, 6

Dual Antiplatelet Therapy

• For patients with coronary stents, do NOT routinely stop dual antiplatelet therapy; manage in liaison with cardiology 3
• In unstable hemorrhage, continue aspirin if the P2Y12 receptor antagonist is interrupted 3
• Restart P2Y12 receptor antagonist within 5 days 3, 1

Organizational Requirements

All hospitals routinely admitting GI bleeding patients must have: 3, 1

• A designated GI bleeding lead clinician responsible for integrated care pathways
• Access to 7-day-per-week on-site colonoscopy with endoscopic therapy capabilities
• Access to 24/7 interventional radiology either on-site or via formalized referral pathway

Critical Pitfalls to Avoid

• Do NOT rush to colonoscopy in unstable patients (shock index >1); this delays definitive CTA localization and potential embolization 1, 3
• Do NOT assume bright red rectal bleeding is always lower GI; 10-15% originates from the upper GI tract, especially with hemodynamic instability 1, 3
• Do NOT perform colonoscopy without adequate bowel preparation; poor prep leads to 70% repeat-procedure rates and missed lesions 1, 3
• Do NOT use fresh frozen plasma as first-line reversal for warfarin; use 4-factor prothrombin complex concentrate plus low-dose vitamin K 1
• Do NOT perform surgery without prior radiologic localization; blind resection carries 33% rebleeding and 33-57% mortality 1, 3

Mortality Context

• Overall in-hospital mortality for LGIB is 3.4%, rising to 18% for inpatient-onset bleeding and 20% for patients requiring ≥4 units of red blood cells 3, 1
• Mortality is generally related to comorbidity rather than exsanguination 3, 1
• UGIB mortality is approximately 10% overall 5