GI BLEED — COMPLETE MEDICAL MANAGEMENT GUIDE

1. IMMEDIATE PRIORITIES (ALL GI BLEEDS)

  • Airway Management:

    • Protect the airway immediately to prevent aspiration of blood.

    • Intubate if there is massive hematemesis, signs of aspiration, or altered mental status (AMS) with a Glasgow Coma Scale (GCS) score typically less than 8, or if airway patency is otherwise compromised.

  • Access:

    • Establish two large-bore peripheral intravenous lines (16 gauge or larger) for rapid fluid and blood product administration.

    • Central venous access (e.g., femoral or subclavian) may be considered for patients requiring massive transfusion or vasopressor support.

  • Fluids:

    • Administer isotonic crystalloid fluids (e.g., 0.9% Normal Saline or Lactated Ringer's solution) to maintain hemodynamic stability.

    • Titrate fluids to support mean arterial pressure (MAP) above 65-70 mmHg and ensure adequate end-organ perfusion.

    • Caution with aggressive fluid resuscitation in variceal bleeds, as it can increase portal pressure; goal is euvolemia, not overhydration.

  • Transfusion Protocols:

    • Transfusion of packed red blood cells (PRBCs) is generally indicated if hemoglobin (Hb) is less than 7 g/dL in hemodynamically stable patients.

    • Consider transfusion if Hb is less than 8 g/dL for patients with significant comorbidities such as coronary artery disease (CAD), active myocardial ischemia, or other critical organ ischemia.

    • Perform a type and crossmatch promptly upon arrival.

  • Coagulation Management:

    • Administer platelets if the platelet count is less than 50,000/µL and there is active bleeding; a target of >50,000/µL is generally recommended.

    • INR reversal should be conducted based on the severity of the bleed and the specific anticoagulant.

    • For patients on Warfarin with an elevated INR and active bleeding, administer 4-factor prothrombin complex concentrate (4F-PCC) at 25-50 units/kg IV based on INR, and 10 mg of vitamin K IV. Fresh Frozen Plasma (FFP) can be an alternative if PCC is unavailable, but requires larger volumes and longer infusion times.

    • For patients on direct oral anticoagulants (DOACs):

    • Use andexanet alfa for rivaroxaban/apixaban reversal (dosing based on last dose and time since administration).

    • Use idarucizumab (5 g IV) for dabigatran reversal.

    • For other DOACs (e.g., edoxaban), activated charcoal may be considered if ingestion was recent (<2 hours), or consider 4F-PCC as a general hemostatic agent.

2. UPPER GI BLEED — VARICEAL

  • Octreotide Administration:

    • Administer a 50 mcg IV bolus followed by a continuous infusion of 50 mcg/hr for 2–5 days.

    • Octreotide, a somatostatin analog, reduces splanchnic blood flow and portal pressure, thereby decreasing variceal bleeding.

  • Antibiotics:

    • Administer ceftriaxone at a dose of 1 g IV daily for 7 days to prevent bacterial infections, particularly spontaneous bacterial peritonitis (SBP), which is common in cirrhotic patients with GI bleeding.

    • Other alternatives include fluoroquinolones (e.g., ciprofloxacin) if ceftriaxone is contraindicated or local resistance patterns dictate.

  • Proton Pump Inhibitor (PPI):

    • Administer pantoprazole as an 80 mg IV bolus followed by an 8 mg/hr continuous infusion, or 40 mg IV twice daily.

    • While primary for non-variceal bleeds, PPIs are often co-administered in variceal bleeds due to the high likelihood of concomitant gastritis or peptic ulcer disease.

  • Endoscopy:

    • Perform an emergent esophagogastroduodenoscopy (EGD) within 12 hours of presentation to confirm source and provide definitive treatment.

    • Endoscopic Variceal Ligation (EVL) with band ligation is the preferred method for actively bleeding esophageal varices.

    • Sclerotherapy may be used if banding is technically difficult or for gastric varices.

  • If refractory to treatment:

    • Consider transjugular intrahepatic portosystemic shunt (TIPS) for patients with persistent or recurrent bleeding despite medical and endoscopic therapy, typically within 72 hours of failed initial management.

    • Balloon Tamponade (Sengstaken-Blakemore or Minnesota tube) is a temporary salvage measure for massive uncontrolled bleeding, but carries risks of esophageal necrosis and aspiration; typically used for a maximum of 24 hours until definitive treatment can be arranged.

3. UPPER GI BLEED — NON-VARICEAL

  • PPI Protocol:

    • For high-risk non-variceal bleeds (e.g., Forrest Ia/Ib/IIa lesions identified on EGD), administer high-dose PPI therapy: an 80 mg IV bolus of pantoprazole or esomeprazole followed by an 8 mg/hr continuous infusion for 72 hours.

    • For lower-risk stigmata or after stabilization, step down to oral PPI (e.g., pantoprazole 40 mg PO daily or twice daily).

  • Endoscopy Timing:

    • Perform EGD within 24 hours of presentation for most non-variceal upper GI bleeds.

    • An earlier EGD (within 12 hours) may be considered for hemodynamically unstable patients or those with evidence of active bleeding (e.g., persistent hematemesis or coffee-ground aspirate).

  • Endoscopic Therapy:

    • Indicated if high-risk stigmata are present during EGD, including:

    • Active arterial spurting (Forrest Ia)

    • Non-bleeding visible vessel (Forrest IIa)

    • Adherent clot (Forrest IIb)

    • Therapeutic modalities include epinephrine injection, thermal coagulation (e.g., bipolar electrocoagulation, heater probe), or mechanical therapy (e.g., hemostatic clips).

  • Helicobacter pylori Testing/Treatment:

    • Test all patients with peptic ulcer disease for H. pylori infection using non-invasive (urea breath test, stool antigen) or invasive (biopsy during EGD) methods.

    • Treat positive H. pylori infections with a clarithromycin-based triple therapy or bismuth quad therapy for 10–14 days, as eradication reduces ulcer recurrence and rebleeding risk.

  • NSAIDs:

    • Advise strict avoidance of non-steroidal anti-inflammatory drugs (NSAIDs) due to their detrimental effect on gastric mucosa by inhibiting prostaglandin synthesis, leading to ulcer formation and impaired healing.

    • If NSAID use cannot be avoided, consider co-administration of a PPI.

4. LOWER GI BLEED

  • Initial Steps:

    • Stabilize the patient first with volume resuscitation and blood product transfusion as per immediate priorities.

    • Exclude an upper GI source of bleeding, especially in cases of suspected massive lower GI bleed, by performing an NG aspirate. A clear NG aspirate typically excludes an active upper GI bleed, though a bile-stained aspirate and no blood can also exclude it unless there's active bleeding distal to the pylorus.

  • Colonoscopy:

    • Should be performed within 24 hours after adequate bowel preparation (e.g., polyethylene glycol solution).

    • This allows for visualization, diagnosis, and potential endoscopic therapy (e.g., clip placement for diverticular bleeding, argon plasma coagulation for angiodysplasia).

  • Etiology Considerations:

    • Diverticular Bleeding: Often self-limiting in 70-80% of cases. If bleeding persists or is severe, endoscopic clipping, IR embolization, or surgical resection may be required.

    • Angiodysplasia: Common cause, especially in older patients and those with renal disease. May be treated endoscopically with argon plasma coagulation or cautery.

    • Ischemic Colitis: Treat with supportive care including fluids and antibiotics (broad-spectrum, e.g., third-generation cephalosporins and metronidazole) to prevent bacterial translocation and manage complications.

    • Inflammatory Bowel Disease (IBD) Flare: Administer IV steroids (e.g., methylprednisolone) for acute exacerbations, potentially combined with immunomodulators or biologics.

    • Radiation Proctitis: For chronic radiation proctitis, use sucralfate enemas to protect mucosa or argon plasma coagulation (APC) for telangiectasias. For acute symptoms, symptomatic management.

    • Hemorrhoids/Anal Fissure: Usually managed conservatively, but can cause significant bleeding. Rubber band ligation or surgical intervention may be required for refractory cases.

    • Post-polypectomy Bleeding: Can be immediate or delayed. Endoscopic clipping or thermal therapy is often effective.

    • Massive Lower GI Bleeding:

    • In hemodynamically unstable patients or those with brisk ongoing bleeding where colonoscopy is not feasible or fails, perform CT angiography (CTA) to localize the bleeding source. CTA can detect bleeding rates as low as 0.3 mL/min.

    • Follow positive CTA with interventional radiology (IR) embolization; success rates are between 85-95%. Surgical intervention is reserved for failed embolization or severe instability.

5. IR-SPECIFIC MANAGEMENT

  • Indication for CTA:

    • CTA is indicated for patients with brisk or ongoing GI bleeding (both upper and lower) when the source is not localized by endoscopy, or when endoscopy is contraindicated.

    • It can identify active extravasation of contrast, which pinpoints the bleeding site, and can guide subsequent embolization.

  • Embolization Techniques:

    • Utilize superselective embolization with various embolic agents, including coils (permanent occlusion), particles (e.g., polyvinyl alcohol, gelfoam for temporary occlusion), or liquid embolics (e.g., n-butyl cyanoacrylate).

    • The goal is to achieve hemostasis while preserving blood flow to surrounding tissues to minimize the risk of ischemia or infarction.

  • Octreotide Note:

    • Octreotide is specifically targeted at reducing splanchnic blood flow associated with portal hypertension and variceal bleeding. It is not indicated in cases of lower GI bleeding of non-variceal origin, as its mechanism is not relevant to these etiologies.

6. ADJUNCTS

  • Erythromycin Administration:

    • Optional: administer erythromycin 250 mg IV 30-60 minutes prior to esophagogastroduodenoscopy (EGD).

    • As a prokinetic agent, erythromycin can improve visualization during EGD by promoting gastric emptying and clearing blood clots, thereby potentially increasing diagnostic yield and reducing the need for repeat procedures.

  • Nasogastric (NG) Lavage:

    • This procedure is optional and may be utilized in certain clinical scenarios to confirm an upper GI source of bleeding or assess the rate of bleeding.

    • However, a negative NG lavage (non-bloody aspirate) does not definitively rule out an upper GI bleed, especially if the bleeding is distal to the pylorus or intermittent.

  • Massive Transfusion Protocol (MTP):

    • Consider MTP for patients with massive hemorrhage and signs of exsanguination or predicted high blood loss (e.g., >10 units PRBCs in 24 hours).

    • MTP typically involves a 1:1:1 ratio of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets to optimally manage coagulopathy associated with severe bleeding and prevent the