Rapid Clinical Updates: Updates in Gastrointestinal Bleed-Handout

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This clinical update focuses on the management of gastrointestinal (GI) bleeding, differentiating between non-variceal and variceal causes, and considerations for patients on direct oral anticoagulants (DOACs).<br /><br />For non-variceal upper GI bleeding, risk stratification using the Glasgow-Blatchford score (0-1 indicating low risk) aids decision-making for safe discharge from the emergency department. Similarly, the Oakland score (≤8) identifies low-risk patients with lower GI bleeding. Administering intravenous erythromycin one hour prior to endoscopy can improve visualization and therapeutic success, suggesting a potential quality-improvement target. Proton-pump inhibitors (PPIs) remain important for mucosal healing; however, current guidance emphasizes tailoring the intensity and duration of PPI therapy based on endoscopic findings to avoid overtreatment.<br /><br />In variceal bleeding associated with portal hypertension, early administration of blood products, antibiotics, and vasoactive agents like octreotide is standard. Though the ideal timing of endoscopy is unclear, early intervention is favored in critically ill patients, while a delay up to 24 hours may be acceptable in others.<br /><br />For patients on DOACs experiencing GI bleeding, routine coagulation tests are unhelpful. Specific reversal agents—idarucizumab for direct thrombin inhibitors and andexanet alfa for factor Xa inhibitors—are available but extremely costly. Their use is recommended only for severe, life-threatening bleeding characterized by shock, significant hemoglobin drop (≥5 g/dL), or need for multiple transfusions (≥5 units).<br /><br />Overall, these updates underscore the importance of risk stratification, targeted pharmacologic intervention, process improvements like prokinetic use before endoscopy, and judicious use of expensive reversal agents in managing GI bleeding.

Keywords

gastrointestinal bleeding

non-variceal bleeding

variceal bleeding

direct oral anticoagulants

Glasgow-Blatchford score

Oakland score

erythromycin pre-endoscopy

proton-pump inhibitors

octreotide

reversal agents for DOACs