Rapid Clinical Updates: Updates in Gastrointestinal Bleed-Slides

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This document summarizes a clinical teaching session led by Drs. Benjamin Verplanke, Marijeta Pekez, and Jagriti Chadha focused on updates in the management of gastrointestinal bleeding (GIB), referencing 2021 and 2023 ACG guidelines.

Key topics include:

1. <strong>Epidemiology and Types of GI Bleeds</strong>: Upper GI bleeding (UGIB) constitutes about 75% of acute GI bleeds, with peptic ulcer disease as the most common cause. Lower GI bleeding (LGIB) has different etiologies including diverticulosis, vascular lesions, and cancer.

2. <strong>Risk Stratification and Admission Decisions</strong>: Tools like the Glasgow-Blatchford score for UGIB and Oakland score for LGIB help identify low-risk patients safe for outpatient management. Most patients with UGIB are admitted, though very low-risk cases may be discharged with close follow-up.

3. <strong>Initial Management and Use of Proton Pump Inhibitors (PPI)</strong>: High-dose intravenous PPIs (e.g., pantoprazole) are recommended before endoscopy but should not delay urgent endoscopy. The role of prokinetics like erythromycin to improve endoscopic visualization has conditional recommendations.

4. <strong>Endoscopic Hemostasis Methods</strong>: Techniques include injection therapy, thermal coagulation, and mechanical methods (clips, band ligation). Second modalities improve outcomes compared to epinephrine alone. Variceal bleeding requires stabilization, antibiotics, vasoactive drugs, and endoscopic variceal ligation or stenting.

5. <strong>Management of GIB in ICU and Use of Hemostatic Powders</strong>: Bedside endoscopy is valuable in ICU patients. Hemostatic agents like TC-325 (Hemospray) serve as temporary control for bleeding, especially in malignant cases.

6. <strong>Anticoagulation Management During GI Bleeds</strong>: Guidance on reversing anticoagulants like warfarin (via PCC, vitamin K) and DOACs (idarucizumab for dabigatran; andexanet for apixaban/rivaroxaban) is detailed. Clinical severity dictates urgency. Reinitiation of antithrombotics post-procedure balances bleeding and thromboembolic risks.

7. <strong>Use of Imaging and Intervention for LGIB</strong>: CT angiography is recommended for ongoing significant bleeding. Positive CTA findings warrant prompt interventional radiology for embolization, with colonoscopy used for diagnosis and treatment in selected stable cases.

Through illustrative clinical cases, the teaching emphasizes evidence-based approaches for assessment, stabilization, endoscopic and medical therapies, and multidisciplinary coordination in GI bleed management. The session closes by reinforcing guideline-concordant care and highlighting key clinical decision points for trainees and attending physicians.
Keywords
gastrointestinal bleeding
upper GI bleeding
lower GI bleeding
risk stratification
proton pump inhibitors
endoscopic hemostasis
variceal bleeding
anticoagulation management
CT angiography
hemostatic powders