GI Bleed: Upper vs Lower — Resuscitation & Endoscopy Timing

GI hemorrhage is a resuscitation problem first and a localization problem second. Stabilize, risk-stratify, reverse what you safely can, and time endoscopy/colonoscopy to change outcomes.

Immediate Priorities (first 10 minutes)

• ABCs & monitoring: airway risk in brisk hematemesis; large-bore IVs; cardiac/SpO₂/telemetry.
• Labs: CBC, CMP, PT/INR, aPTT, type & screen/cross, VBG/lactate. Pregnancy test when relevant.
• IV fluids: balanced crystalloids in hypotension while arranging blood if needed.
• Transfusion: restrictive threshold around Hgb ~7 g/dL for most; higher in active ischemia, severe CAD, or exsanguination. Platelets if severe thrombocytopenia with active bleed.

Upper vs Lower Clues

• Upper GI: hematemesis, “coffee ground,” melena, BUN>Cr ratio elevated, history of PUD/NSAIDs, cirrhosis/varices.
• Lower GI: hematochezia, maroon stool, anemia without melena; brisk upper bleeds can also present with hematochezia.

Risk Tools (guide timing & level of care)

• Glasgow-Blatchford Score (GBS): pre-endoscopy risk in suspected upper GI bleed—low scores may allow early discharge with outpatient endoscopy.
• Rockall (post-endoscopy) refines rebleed/mortality risk.
• Oakland can aid disposition in lower GI bleed.

Empiric Medical Therapy (suspected upper GI)

• PPI: high-dose IV PPI (e.g., bolus + infusion or intermittent high-dose) before endoscopy for non-variceal UGIB.
• Variceal concern (cirrhosis/signs of portal HTN): start octreotide infusion and prophylactic antibiotics (e.g., ceftriaxone) early; coordinate with hepatology/GI.
• Antiemetics for hematemesis to reduce aspiration risk.

Reversal & Antithrombotics

• Antiplatelets: continue aspirin for secondary prevention when possible; hold P2Y12 only after risk–benefit discussion (stents!).
• Warfarin: vitamin K ± PCC for serious bleeding.
• DOACs: hold; consider specific reversal (idarucizumab for dabigatran; andexanet or PCC for factor-Xa inhibitors per local protocol).
• Heparin: protamine for UFH; partial effect for LMWH.

Endoscopy & Colonoscopy Timing

• Upper GI bleed (non-variceal): endoscopy within 24 h after resuscitation; sooner if ongoing hemodynamic instability.
• Variceal bleed: urgent endoscopy (often <12 h) after starting octreotide and antibiotics; consider balloon tamponade/TIPS consultation if refractory.
• Lower GI bleed: colonoscopy within 24 h after adequate prep if ongoing bleeding; CT angiography can localize brisk hemorrhage and guide IR embolization.
• Massive/obscure: CTA or tagged RBC scan; early IR and surgery consults when unstable.

Post-Endoscopy Management (non-variceal UGIB)

• Endoscopic hemostasis (clips/thermal/injection) followed by high-dose PPI regimen (e.g., 72 h infusion or equivalent intermittent dosing), then daily PPI.
• H. pylori testing and eradication if positive; stop NSAIDs when possible; resume anticoagulation with a risk-based plan.

Lower GI Bleed: Pearls

• Diverticular bleeding is common and often self-limited; identify high-risk features for admission.
• Consider ischemic colitis in older patients with pain + hematochezia—supportive care and targeted imaging.
• Anticoagulated patients: coordinate timing of resumption once hemostasis achieved based on thrombotic risk.

Disposition Logic

• Admit if hemodynamic instability, ongoing transfusion needs, significant comorbidity, high GBS/Oakland, or unclear source with recurrent bleeding.
• Observation/outpatient for low-risk, stabilized patients with clear plan and early follow-up.

Patient FAQs

“Why not give me more blood right away?” Restrictive transfusion improves outcomes in many GI bleeds and avoids complications; we tailor to your risks and symptoms.

“Can I restart my blood thinner?” Often yes after hemostasis—timing depends on rebleed vs thrombosis risk; your team will decide with you.

References & Notes

Practical pathway aligning with common GI/ER practice: early resuscitation, risk scoring, PPI ± octreotide/antibiotics when indicated, and timely endoscopy/colonoscopy/CTA based on stability and source. Educational only—follow local protocols.