Gastrointestinal hemorrhage can be lethal, but fortunately, the management is usually cognitively straightforward. Most patients do fine. Our job is to put blood into the patient faster than the blood is leaving the patient until a gastroenterologist, interventional radiologist, or surgeon can perform procedures to achieve a definitive diagnosis and management strategy.
The treatment of a GI bleed varies based on whether or not it is coming from the upper or lower GI tract, and whether or not the patient has cirrhosis or portal hypertension.
Follow the steps in the listed order.
Remember that resuscitating the patient is the first priority.
Upper GI Bleed
Low Suspicion for Cirrhosis
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Assess hemodynamic stability.
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Get and maintain IV access.
Two large-bore peripheral IVs is ideal. A common question is whether or not peripheral IVs or a central line is better. The longer length of a central line increases resistance to flow, peripheral IVs are generally preferable because blood can be transfused through them faster. You want the shortest, widest intravenous catheter you can get. Generally, an 18G PIV in each AC is good enough.
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Start volume resuscitation with crystalloid.
But if the patient is unable, give un-crossmatched blood ASAP
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Obtain a type and screen.
Consent the patient to receive blood, even if not yet necessary.
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Give IV PPI.
A historical standard was pantoprazole, 80mg IV bolus followed by IV drip, but 40mg IV pantoprazole q12h is likely equivalent and easier.
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Make patient NPO.
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Check a CBC.
Transfuse blood if needed for hemodynamic instability or to meet the patient's transfusion threshold. This is usually a hemoglobin of 7 or greater, but for select patients (those with active ACS, for example), a goal of 8 is more appropriate. Keep the platelets at 50 or greater. Hold anticoagulants.
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Call GI to discuss the case.
Request that the patient be put on the schedule for upper endoscopy when the sun comes up. If the patient is hemodynamically unstable despite resuscitation with blood products, GI should be called in overnight for emergent upper endoscopy. Other options for emergent treatment of the bleed are via interventional radiology or surgical intervention.
High Suspicion for or Known Cirrhosis
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Assess hemodynamic stability.
-
Get and maintain IV access.
Two large-bore peripheral IVs is ideal. A common question is whether or not peripheral IVs or a central line is better. Because the longer length of a central line increases resistance to flow, peripheral IVs are generally preferable because blood can be transfused through them faster. You want the shortest, widest intravenous catheter you can get. Generally, an 18G PIV in each AC is good enough.
-
Start volume resuscitation with crystalloid.
But if the patient is unable, give un-crossmatched blood ASAP
-
Obtain a type and screen.
Consent the patient to receive blood, even if not yet necessary.
-
Make patient NPO.
If large volume hematemesis or massive variceal hemorrhage is suspected, consider intubation for airway protection. Stabilize BP before intubation.
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Give IV PPI.
A historical standard was pantoprazole, 80mg IV bolus followed by IV drip, but 40mg IV pantoprazole q12h is likely equivalent and easier.
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Give octreotide bolus and start continuous infusion.
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Give ceftriaxone
1g qd x 5–7 days for infection prophylaxis, if not already on broad spectrum antibiotics.
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Check a CBC, INR, and fibrinogen.
Transfuse blood if needed for hemodynamic instability or to meet the patient's transfusion threshold. This is usually a hemoglobin of 7 or greater, but for select patients (for example, those with active ACS), a goal of 8 is more appropriate. Keep the platelets at 50 or greater. Try to get the INR below 2 with FFP. Try to get the fibrinogen > 100–150 with cryoprecipitate. Hold anticoagulants.
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Call GI to discuss the case.
Patient may need emergent endoscopy and variceal banding. If banding is unsuccessful, emergent TIPS with interventional radiology is an option. In dire situations, balloon tamponade can be used to temporarily stop variceal bleeding.
Lower GI Bleeding
-
Assess hemodynamic stability.
-
Get and maintain IV access.
Two large-bore peripheral IVs is ideal. A common question: Is a peripheral IV or a central line better? Because the longer length of a central line increases resistance to flow, peripheral IVs are generally preferable because blood can be transfused through them faster. You want the shortest, widest intravenous catheter you can get. Generally, an 18G PIV in each AC is good enough.
-
Start volume resuscitation with crystalloid,
But if the patient is unable, give un-crossmatched blood ASAP
-
Obtain a type and screen.
Consent the patient to receive blood, even if not yet necessary.
-
Start IV pantoprazole,
if the bleed is brisk and not certain to be lower GI, just in case.
-
Make patient NPO.
-
Check a CBC.
Transfuse blood if needed for hemodynamic instability or to meet the patient's transfusion threshold. This is usually a hemoglobin of 7 or greater, but for select patients (those with active ACS, for example), a goal of 8 is more appropriate. Keep the platelets at 50 or greater. Hold anticoagulants.
-
Call GI to discuss the case.
When the sun comes up, the patient will likely need a lower endoscopy. If the patient remains unstable despite resuscitation with blood products, they may need emergent assessment by an interventional radiologist or surgeon, or less likely emergent colonoscopy. CT angiography may be necessary to localize the bleed.
Image credit: Eric Tanenbaum.
