ASGE Annual GI Advanced Practice Provider Course (Virtual) (Day Two) | March 2026-GI Bleeding: Comprehensive Management Across the GI Tract

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This presentation reviews comprehensive management of gastrointestinal (GI) bleeding across upper, small bowel, and lower GI sources. GI bleeding is a common and costly cause of hospitalization in the U.S. (over 500,000 admissions annually). Bleeding is categorized anatomically as upper GI bleeding (UGIB, proximal to the ligament of Treitz), small bowel bleeding, or lower GI bleeding (LGIB, distal to the ileocecal valve). Initial triage prioritizes stabilization and source identification: hematemesis/melena suggests UGIB, while hematochezia suggests LGIB or brisk UGIB. Early management includes two large-bore IVs, crystalloid resuscitation, and transfusion targeting hemoglobin ~7 g/dL for most patients. UGIB risk stratification uses the Glasgow-Blatchford Score pre-endoscopy, while the Rockall score helps predict rebleeding and mortality after endoscopy.<br /><br />UGIB etiologies include peptic ulcer disease (most common), varices, Mallory-Weiss tears, erosive esophagitis/gastritis (often NSAID-related), and Dieulafoy lesions. Pharmacologic therapy emphasizes high-dose IV proton pump inhibitors; octreotide and ceftriaxone are added when variceal bleeding/cirrhosis is suspected. Endoscopy is recommended within 24 hours for most UGIB and within 12 hours for suspected variceal bleeding. Post-endoscopic care includes continuing IV PPI infusion for 72 hours, testing and eradicating H. pylori, individualized decisions on restarting antithrombotics, and considering repeat endoscopy.<br /><br />Small bowel (“obscure”) bleeding accounts for 5–10% of cases, commonly from AVMs, NSAID ulcers, Meckel’s diverticulum, or tumors. Workup may include repeat EGD/colonoscopy, video capsule endoscopy (gold standard visualization), and deep enteroscopy for therapy.<br /><br />LGIB is often intermittent and self-limited, with causes including diverticular bleeding, angiodysplasia, ischemic colitis, IBD, and hemorrhoids. Management stresses ruling out UGIB, performing rapid bowel prep for colonoscopy, and using CTA, tagged RBC scanning, or interventional radiology when needed. Anticoagulant reversal strategies (warfarin vs DOAC-specific agents) and timing of restart (often 7–14 days) are also reviewed, along with endoscopic hemostasis tools such as clips and hemostatic powders.

Asset Subtitle

Sarah Kosinski, DNP, APRN, FNP-BC, and John A. Martin, MD, FASGE

Keywords

gastrointestinal bleeding management

upper GI bleeding (UGIB)

lower GI bleeding (LGIB)

small bowel (obscure) bleeding

Glasgow-Blatchford Score

Rockall score

endoscopy timing and hemostasis

proton pump inhibitor (IV PPI) therapy

variceal bleeding (octreotide ceftriaxone)

CT angiography and interventional radiology