Gastrointestinal Bleeding: Therapy

Thank you procedure and risk assessment

• The approach to gastrointestinal bleeding (GIB) must be based primarily on the clinical symptoms and localization of the source of bleeding.
  • Occult hemorrhage can be promptly evaluated as an outpatient at rest:
    • Esophago-gastro-duodenoscopy (ÖGD; endoscopic examination of the esophagus (food pipe), the gaster (stomach)) and the duodenum (duodenum)) and/or
    • Ileocolonoscopy (endoscopic examination of the colon (large intestine), caecum (appendix), and terminal ileum (the last ten to 15 centimeters of the ileum)).
    • Capsule endoscopy (if a mid GIB is suspected).
  • Severe hemorrhagic shock requires prompt inpatient diagnosis and therapy.
• For the initial risk assessment, a medical history including medication history (if necessary, also foreign history), which is followed by a clinical examination and the collection of vital signs (blood pressure, heart rate, O2 saturation).
• Typically, upper GIB leads more frequently to hospital admission than lower GIB.

Treatment of gastrointestinal bleeding (GI bleeding, GIB) generally depends on the cause:

Bleeding type	Outpatient or inpatient	Therapy or procedure
Nonvariceal hemorrhage (e.g., ulcer disease, anticoagulation)	Outpatient or inpatient, depending on risk assessment	Proton pump inhibitors (e.g., pantoprazole 80 mg i.v. ; bolus, then continue i.v.) 30 minutes before the index endoscopyonce the i.v. administration of 250 mg erythromycin. Endoscopy immediately (< 12 h) in shock, promptly (< 24 h) in risk constellation, early selective (< 72 h) in stable situation.
Varicose hemorrhage (e.g., known cirrhosis of the liver)	Immediate hospital admission	Proton pump inhibitors (e.g., pantoprazole 80 mg i.v. ; bolus, then continue i.v.) [also used in varicose hemorrhage, as the distinction between varicose and nonvaricose hemorrhage is not reliable] Vasoconstrictor i.v. (terlipressin, somatostatin, or octreotide goes); and In addition, an antibiotic i.v. (eg, ceftriaxone or ciprofloxacin; for about 5 days). Approximately 30-120 minutes before the index endoscopyone-time i.v. administration of 250 mg erythromycin. Endoscopy is performed as early as possible in shock, otherwise promptly (< 12 h).
Suspected lower gastrointestinal bleeding (fecal occult blood, occasional blood accumulation)	If the clinical situation is clearly stable and the risk profile is low, outpatient
Suspected lower gastrointestinal hemorrhage and evidence of acute risk from the hemorrhage (e.g., intermittent severe hematochezia with vegetative response)	Immediate inpatient admission
Hemorrhagic shock associated with suspected nonvariceal upper gastrointestinal hemorrhage	Immediate hospital admission	After circulatory stabilization, emergency endoscopy (within 12 h). In high-risk situations and suspected nonvariceal upper gastrointestinal bleeding, endoscopy should be performed promptly (within 24 h). In suspected nonvariceal upper gastrointestinal bleeding and hemodynamic stability, endoscopy should be performed early (within 72 h).

Notice:

• Emergency endoscopy for hemostasis is also possible and reasonable under antiplatelet agents or anticoagulants.
• In atrial fibrillation, bridging therapy perioperatively with low-molecular-weight heparin is no longer recommended

Approximately 80% of GIBs resolve spontaneously, that is, stop bleeding on their own. In gastrointestinal bleeding, targeted hemostasis is performed according to the so-called EURO concept:

• Endoscopy (viewing of the affected organ by means of fiber optics).
• Injection (with NaCl 0, 9% and/or epinephrine), fibrin glue, clipping (clipping), laser coagulation.
• Assess risk of recurrence (risk of recurrence).
• Operate

Other hints

• For endoscopic control of nonvariceal bleeding, injection therapy, mechanical occlusion (hemoclips), and thermal methods (“heat-based”: e.g.B. Radiofrequency ablation) can be used.
• For bleeding that does not arrest using standard procedures, “over-the-scope clips” or hemostasis sprays can be used.
• For high-risk stigmata (stages: FIa, FIb, FIIa), a second endoscopic hemostasis procedure (mechanical or thermal) should be performed after initial injection therapy to prevent recurrent hemorrhage (recurrence of bleeding).
• In high-risk patients with upper gastrointestinal bleeding, rapid endoscopy has not been shown to be beneficial: The study’s primary endpoint (death within the first 30 days) occurred 8.9% more often after early endoscopy than in the control group, where only 6.6% of patients died within the first 30 days. In the control group, the average time to endoscopy was 16.8 hours; in the “Urgent” group, 2.5 hours.It is possible that acid inhibition, which was performed immediately in both groups of patients, promoted the healing of ulcers (boils) in the control group, from which bleeding was most common.
• Bleeding from neoplasms (neoplasms) in the gastrointestinal tract should be treated primarily by endoscopy.

For esophageal variceal bleeding, rubber band ligation is the standard therapy.

Drug therapy

The following symptomatic therapy can be given initially:

• Shock control, i.e., lie flat, place large-lumen IVs, volume administration, oxygen administration
• If response to volume therapy is inadequate, catecholamines can be used passagerly in hemorrhagic shock to stabilize circulation.
• Red blood cell concentrates
  • Patients with suspected gastrointestinal bleeding should receive allogeneic red cell concentrates so that hemoglobin levels are stabilized between 7-9 g/dL.
  • Red cell concentrates should not be transfused if the hemoglobin level is above 10 g/dl and there are no clinical signs of anemic hypoxia (lack of oxygen due to anemia).
  • In cases of massive gastrointestinal hemorrhage and hemorrhagic shock, red cell concentrates may be given according to clinical judgment (regardless of hemoglobin level).
• Proton pump inhibitors (proton pump inhibitors, PPI; acid blockers) may be given for suspected varicose upper gastrointestinal bleeding (even with varicose bleeding, because the distinction between varicose and nonvaricose bleeding is not reliable)

For detailed drug therapy for shock treatment, see “Shock.”

Surgical therapy

• Variceal hemorrhage: intrahepatic stent-shunt (TIPS; transjugular intrahepatic portosystemic (stent) shunt; angiographically created connection between the portal vein and the hepatic vein through the liver (portosystemic shunt)) may better prevent recurrent bleeding from esophageal varices (varicose veins of the esophagus).
• Bleeding from the stomach:
  • Application of ligature rubber bands
  • Radiofrequency ablation (RFA) – e.g., in GAVE (gastric antral vascular ectasia) syndrome.
  • Argon plasma coagulation (APC) – for bleeding from angiodysplasias (small foci or nodules of blood vessels, especially small arteries).
• Acute peptic ulcer bleeding (gastric juice-induced ulcers): hemospray to stop bleeding and 72 h high-dose proton pump inhibitors (proton pump inhibitors, PPI
• Dieulafoy ulcer (Dieulafoy lesion or exulceratio simplex) is a rare form of bleeding peptic ulcer (ulcus ventriculi); endoscopic band ligation more efficient compared to electrocoagulation with a hemostasis rate of over 90 percent.
• Radiogenic proctitis (radiotherapy-related inflammation of the rectum) – radiofrequency ablation (RFA).

Further notes

• Emergency endoscopy for hemostasis is also possible and useful under antiplatelet agents or anticoagulants.
• In acute bleeding or clinically unstable situation, anticoagulation should be suspended until emergency endoscopy.
• In severe gastrointestinal bleeding, anticoagulation (NOAKs, vitamin K antagonist) may be antagonized before endoscopic hemostasis.
• Propofol appears to be safe as a sedative for emergency endoscopy in gastrointestinal hemorrhage.
• Intravenous daily prophylaxis of stress ulcer (= stress prophylaxis) in intensive care patients with pantoprazole (40 mg bolus) may slightly reduce the rate of gastrointestinal bleeding but was without effect on mortality.