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Severe gastrointestinal bleeding
Gastrointestinal bleeding is common, and severe bleeding often requires intensive care unit admission. Optimal management requires hemostatic resuscitation, management of antiplatelet and anticoagulant agents, acid suppression, and a multidisciplinary approach to localization for hemorrhage control, summarized in Fig. 93.1 .
Severe Gastrointestinal Bleeding Management Algorithm.
ACS , Acute coronary syndrome; CT , computed tomography; PCI , percutaneous coronary intervention; PCC , prothrombin complex concentrate; TIPS , transjugular intrahepatic portosystemic shunt.
Resuscitation
For patients with acute upper gastrointestinal bleeding, restrictive transfusion strategies (i.e., red cell transfusion when hemoglobin falls below 7 g/dL) decreases mortality and morbidity relative to liberal transfusion strategies. , It is reasonable to maintain a higher threshold (e.g., hemoglobin 9 g/dL) in patients with ischemic cardiovascular disease. Although there is a lack of high-level evidence to inform decisions regarding red cell transfusion strategies specifically for acute lower intestinal bleeding, it seems prudent to adopt a restrictive transfusion strategy for these patients as well. , In cases of hemorrhagic shock, hemostatic resuscitation should proceed with balanced administration of red cells and plasma, in addition to platelet transfusions for patients with thrombocytopenia or the use of antiplatelet medications.
Management of antiplatelet agents
Management of antiplatelet therapy for patients with severe gastrointestinal bleeding depends on the indication for and type of antiplatelet therapy. When the indication is primary prevention of cardiovascular events, antiplatelet therapy should be discontinued. When the indication is secondary prevention of cardiovascular events in patients with known cardiovascular disease, low-dose aspirin monotherapy should be continued, and for patients receiving dual antiplatelet therapy, aspirin should be continued and the nonaspirin antiplatelet agent should be held for up to 1 week. If dual antiplatelet therapy is indicated for cardiac percutaneous intervention within the prior 30 days or an acute coronary syndrome within the prior 90 days, it is reasonable to continue dual antiplatelet therapy, given the high risk of myocardial infarction and death associated with discontinuation of dual antiplatelet therapy.
Management of anticoagulants
When severe gastrointestinal bleeding occurs in the context of therapeutic anticoagulation, the anticoagulant should be discontinued, and reversal should be considered. Intravenous administration of vitamin K and prothrombin complex concentrates effectively reverses warfarin. Increasingly, direct thrombin inhibitors (e.g., dabigatran) and factor Xa inhibitors (e.g., rivaroxaban, apixaban, edoxaban, and fondaparinux) are used to prevent embolic stroke in nonvalvular atrial fibrillation and to prevent and treat venous thromboembolism. When patients present within 2–3 hours of ingesting anticoagulants, administration of activated charcoal may decrease their intestinal absorption, but will also impair endoscopic visualization of the gastrointestinal mucosa. Hemodialysis can remove dabigatran from the bloodstream, but is ineffective in removing factor Xa inhibitors because they are highly protein-bound. Idarucizumab, a specific monoclonal antibody, also reverses dabigatran. Fresh frozen plasma and cryoprecipitate have limited efficacy in reversing direct thrombin inhibitor and factor Xa inhibitors. For cases of severe bleeding, prothrombin complex concentrates and the antifibrinolytic agent tranexamic acid may be considered, though evidence supporting their use specifically for gastrointestinal bleeding is limited, and they are associated with thromboembolic complications. It seems prudent to perform rapid thromboelastography and administer tranexamic acid if pathologic thrombolysis is identified, though this area remains controversial. Emerging evidence suggests that andexanet alfa effectively reverses factor Xa inhibitors with an acceptable safety profile, but further investigation is required before routine clinical use can be recommended.
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