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Clinical Strategies for Managing Acute Gastrointestinal Hemorrhage and Anemia Without Blood Transfusion* Contents Page General Management Principles 1

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Clinical Strategies for Managing Acute Gastrointestinal Hemorrhage and Anemia Without Blood Transfusion* Contents Page General Management Principles 1 CLINICAL STRATEGIES FOR MANAGING ACUTE GASTROINTESTINAL HEMORRHAGE AND ANEMIA WITHOUT BLOOD TRANSFUSION* CONTENTS PAGE GENERAL MANAGEMENT PRINCIPLES 1. ASSESSMENT AND INITIAL MANAGEMENT 1. Formulate a comprehensive clinical management plan to facilitate ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ rapid decision-making and avoid treatment delays, integrating a combi- A. Patient History 3 nation of blood conservation modalities. B. Initial Resuscitation ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 3 C. Selective Laboratory Evaluation/Screening ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 3 2. Exercising clinical judgment, be prepared to modify routine practice (e.g., rapid and aggressive arrest of bleeding, tolerance of moderate D. Diagnosis and Localization of Bleeding Site ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 3 hypotension during uncontrolled bleeding). E. Diagnostic Interventions ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 4 3. Discuss anticipated or potential procedures and their risks and bene- F. Maintain a High Level of Clinical Suspicion of Bleeding˝˝˝˝˝˝˝˝4 fits with the patient/substitute decision-maker. 2. PROMPT ARREST OF BLEEDING 4. Ensure the availability of well-trained, experienced personnel and needed drugs and equipment for prevention and rapid control of A. Rapid Diagnosis and Therapy˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 4 hemorrhage. 3. JUDICIOUS VOLUME RESUSCITATION 5. Adopt an interdisciplinary and collaborative team approach among A. Nonblood Volume Expanders ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 5 involved specialties (gastroenterology, medicine, radiology, surgery, anesthesiology, intensive care, hematology) with active management by B. Avoid Excessive Fluid Administration ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 5 the lead clinician. 4. PHARMACOLOGICAL ENHANCEMENT OF 6. Maintain ongoing communication regarding patient management. HEMOSTASIS Where there are multiple conditions treated by multiple physicians, inter- A. Augment Clotting Factor Activity ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 5 specialty collaboration and coordination is particularly important. B. Reverse Anticoagulation˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 5 7. Consult promptly with specialist physicians who have experience in C. ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ the management of patients without allogeneic blood transfusion. Rec- Acid-Suppressive Therapy (Raise Gastric pH) 6 ognition of risk factors for bleeding or anemia may help clinicians to D. Induce Splanchnic Vasoconstriction˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 6 predict/anticipate the need for preventive or control measures. E. Other Agents With Hemostatic Effects ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 6 ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 8. Maintain continuous, close surveillance for signs and symptoms of F. Modify/Discontinue NSAIDs 6 blood loss or deterioration. Set a lower threshold for early intervention in G. Inhibit Fibrinolysis ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 6 patients for whom allogeneic blood transfusion is not an option. 5. UPPER GI BLEEDING 9. Expeditious arrest of blood loss and judicious volume man- agement are life saving. In the actively bleeding patient who cannot be A. Peptic Ulcer Hemorrhage˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 6 transfused, it is not an option to hope that gastrointestinal (GI) bleeding B. Bleeding Gastroesophageal Varices ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 7 will abate spontaneously. All available therapy must be optimized to C. Mallory-Weiss Tears˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 7 reduce blood loss and maintain perfusion. In the face of severe hemor- D. Dieulafoy’s Lesion ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 8 rhage, early recourse to definitive measures to control and arrest bleed- ing is of paramount importance. E. Gastrointestinal Angiomata and Other Conditions ˝˝˝˝˝˝˝˝˝˝˝˝˝ 8 10. Transfer a stabilized patient, if necessary, to a major center before the 6. LOWER GI BLEEDING patient’s condition deteriorates. A. Medical Therapy˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 8 GENERAL THERAPEUTIC PRINCIPLES B. Diverticular Hemorrhage ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 8 C. Angiodysplasias (Vascular Ectasia, Arteriovenous 1. Judicious fluid resuscitation. In the presence of uncontrolled hemorrhage, Malformations)˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 8 consider permissive moderate hypotension and controlled fluid resuscita- D. Anorectal Hemorrhage˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 8 tion until bleeding is promptly arrested so as not to exacerbate ongoing ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ bleeding. Maintain normovolemia in the anemic patient after hemorrhage E. Postpolypectomy Site Bleeding 9 is controlled. F. Inflammatory Bowel Disease (Including Colitis, Crohn’s)˝˝˝˝˝ 9 ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 2. History taking, physical examination, resuscitative measures, diagnostic G. Dieulafoy’s Lesion 9 procedures, lavage, etc., are dynamic processes that may proceed H. Meckel’s Diverticulum˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 9 concomitantly. 7. AVOID IATROGENIC ANEMIA 3. Rapid diagnosis, expeditious localization and arrest of hemorrhage, as well as anticipation and prophylaxis against recurrent hemorrhage are A. Restricted Diagnostic Phlebotomy ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 9 the cornerstones of the management of acute GI bleeding without blood transfusion. 8. ANEMIA MANAGEMENT 4. Use available diagnostic interventions that can most rapidly localize the A. Early Erythropoiesis-Stimulant Therapy˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 9 bleeding site(s). B. Iron Therapy and Hematinic Support ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 10 5. Promptly arrest active bleeding by early institution of specific therapy by well-trained and skilled endoscopists or surgeons. 9. TOLERANCE OF ANEMIA ˝˝˝˝˝˝˝˝˝˝ 6. Use pharmacological agents to suppress gastric acid, improve coagula- A. Moderate Normovolemic Anemia Is Well Tolerated 10 tion status, and promote hemostasis. B. Compensatory Mechanisms in Normovolemic Anemia ˝˝˝˝˝ 10 C. Effects of Stored Red Blood Cell Transfusion˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 10 * This Clinical Strategies document is an informational resource and reference for medical practitioners only. It provides neither medical advice nor treatment recommendations and does not substitute for an appropriately qualified health-care professional. The editor does not recommend or endorse any test, physician, product, or procedure, and has endeavored to include accurate, timely information. However, not all listed strategies are appropriate or acceptable to all patients. It is the responsibility of each provider to maintain awareness of new information, discuss options for care, and assist patients in making choices in accord with their wishes, values, and beliefs. Patients should always seek the advice of a qualified health-care professional regarding a medical condition or treatment. Distributed by Hospital Information Services for Jehovah’s Witnesses http://www.jw.org/en/medical-library 1 ALGORITHM FOR NONBLOOD MANAGEMENT OF GASTROINTESTINAL (GI) BLEEDING GI Bleeding / / / Initial Assessment Resuscitation ˙ Focused History ˙ Judicious Fluid Replacement ˙ Physical Exam ˙ Supplemental Oxygen ˙ ˙ Risk Factor Assessment Gastric Acid-Suppressive Therapy ˙ ˙ Laboratory Evaluation Pharmacological Enhancement of Hemostasis ˙ Temporary Balloon Tamponade / Prompt Identification of Bleeding Source Yes ˙ Esophagogastroduodenoscopy (EGD) No positive? (Upper GI Bleeding) (Lower GI Bleeding) / / No No Is Patient Stable? Is Patient Stable? / Yes Yes / Severity of Bleeding? Severity of Bleeding? Moderate/ Severe/ Severe/ Moderate/ Low Risk High Risk High Risk Low Risk / / / ˙ Early Endoscopic ˙ Emergency Endoscopic Severe/High ˙ Consider Surgical Therapy Therapy Risk Consultation ˙ Hb ˝ 110 g/L or dropping / ˙ Age ˛ 60 ˙ Colonoscopy ˙ Blood loss ˛ ˙ Angiographic Therapy / 750 mL Recurrent Bleeding? ˙ Suspected / No varices ) ˙ Prompt Surgery ˙ / Yes High risk of rebleeding ˙ Repeat Endoscopic/Pharmacological Therapy ˙ Hemodynamic ˙ Angiographic Therapy deterioration / ˙ Comorbidity ˙ / MRI, CT/Angiographic Localization ˙ Colonoscopy & Recurrent Bleeding? ˙ No Enteroscopy / ˙ Scintigraphy / Yes ˙ Angiographic Therapy & ˙ Prompt Surgery ˙ Capsule Endoscopy ˙ Surgery / & Recurrent Bleeding? No Yes / / No ˙ Repeat Pharmacological Therapy Recurrent Bleeding? ˙ Repeat Endoscopic/Angiographic/Surgical Therapy ˙ Capsule Endoscopy Yes ˙ Temporary Balloon Tamponade / ˙ Repeat Pharmacological Therapy / ˙ Repeat Endoscopic/Angiographic/Surgical Therapy ) ˙ Close Monitoring and Anemia Management / / ˙ Treatment to Prevent Recurrence ˙ Close Monitoring and Anemia Management & This algorithm outlines the basic care of patients. Practice will vary according to the clinical situation, local resources, personnel, and expertise. * This Clinical Strategies document is an informational resource and reference for medical practitioners only. It provides neither medical advice nor treatment recommendations and does not substitute for an appropriately qualified health-care professional. The editor does not recommend or endorse any test, physician, product, or procedure, and has endeavored to include accurate, timely information. However, not all listed strategies are appropriate or acceptable to all patients. It is the responsibility of each provider to maintain awareness of new information, discuss
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