Sun, Sand and Stomachs: Updates in GI-Slides

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This presentation reviews recent updates in gastrointestinal (GI) bleeding and Clostridium difficile (C. difficile) management based on the latest ACG guidelines.<br /><br />For upper GI bleeding (UGIB), the 2021 ACG guidelines emphasize risk stratification using tools like the Glasgow-Blatchford score to identify low-risk patients suitable for outpatient management. Initial management includes intravenous proton pump inhibitor (PPI) therapy—namely, pantoprazole bolus followed by infusion—while awaiting endoscopy. Use of erythromycin as a prokinetic agent before endoscopy is conditionally recommended to improve visualization. Endoscopic findings guide therapy, with clean-based ulcers (Forrest III) typically managed with oral PPIs post-discharge. Duration of IV PPI therapy depends on bleeding severity and stigmata.<br /><br />In lower GI bleeding (LGIB), highlighted by the 2023 ACG update, risk assessment with the Oakland score helps identify patients safe for early discharge. Hemodynamically unstable patients may need CT angiography (CTA) to locate bleeding followed by interventional radiology embolization or colonoscopy. Management of anticoagulation and antiplatelet agents is critical: vitamin K antagonists (VKAs) may require reversal with 4-factor prothrombin complex concentrate if life-threatening bleeding occurs, while direct oral anticoagulants (DOACs) may need specific reversal agents like idarucizumab or andexanet alfa. Platelet transfusions are reserved for severe bleeding with thrombocytopenia; antiplatelet therapy is generally continued unless bleeding is severe, with careful consideration for cardiac stents.<br /><br />For C. difficile infection (CDI), fidaxomicin is preferred over vancomycin or metronidazole for initial and recurrent cases, though cost may limit use. In severe or refractory cases, fecal microbiota transplantation (FMT) is recommended, especially in patients unsuitable for surgery. Bezlotoxumab, a monoclonal antibody targeting toxin B, can be used adjunctively to reduce recurrence risk.<br /><br />Overall, these updates emphasize evidence-based risk stratification, targeted medical and procedural interventions, and nuanced management of anticoagulation to improve GI bleeding outcomes and optimize CDI therapy.

Keywords

gastrointestinal bleeding

Clostridium difficile

ACG guidelines

upper GI bleeding

Glasgow-Blatchford score

proton pump inhibitors

erythromycin

lower GI bleeding

Oakland score

fecal microbiota transplantation