Initial Management of Upper Gastrointestinal Bleeding in Patients on Anticoagulants

Initial Resuscitation and Assessment

For patients with upper gastrointestinal bleeding (UGIB) on apixaban, immediate resuscitation with fluid support and blood transfusion targeting a hemoglobin of 70-100 g/L should be initiated, followed by early endoscopy within 24 hours of presentation, as recommended by the American College of Cardiology and other guideline societies 1, 2
Aggressive volume resuscitation and maintenance of hemodynamic stability are the first priorities in patients presenting with substantial UGIB, according to the American College of Radiology 3
Blood transfusion should be given with a target hemoglobin of 70-100 g/L, considering a higher threshold of 80 g/L in patients with cardiovascular disease like non-ischemic cardiomyopathy (NICM), as suggested by the American College of Cardiology and the American Heart Association 1, 2, 4
Risk stratification using the Glasgow Blatchford score can help identify patients at high risk of requiring intervention, as recommended by the American College of Physicians 2
Nasogastric tube placement may be considered in selected patients as findings have prognostic value, according to the American Gastroenterological Association 2

Do not delay endoscopy due to the patient being on apixaban, as recommended by the American College of Cardiology and the American Heart Association 2, 4
For life-threatening hemorrhage in a patient on apixaban, consider reversal agents, such as andexanet alfa, which is the specific reversal agent for apixaban, as suggested by the American College of Cardiology 1

Perform endoscopy within 24 hours of presentation, with earlier endoscopy (after resuscitation) for high-risk patients with hemodynamic instability, as recommended by the American Society for Gastrointestinal Endoscopy and the American College of Radiology 2, 3
Endoscopic therapy is indicated for high-risk stigmata (active bleeding or visible vessel), according to the American Society for Gastrointestinal Endoscopy 2

If endoscopy cannot be performed due to massive bleeding or clinical instability, CT angiography (CTA) should be considered to localize the bleeding source, as recommended by the European Society of Gastrointestinal Endoscopy and the American College of Radiology 5, 6
Visceral angiography can be helpful on an emergent basis for overt large bleeding in unstable patients, especially when the bleeding source is unclear, according to the Society of Interventional Radiology 6
Angiography allows simultaneous treatment by embolization if a bleeding source is identified, as suggested by the Society of Interventional Radiology 6

Do not delay endoscopy in patients on anticoagulants as this can lead to worse outcomes, as warned by the American College of Cardiology and the American Heart Association 2
Do not use prothrombin complex concentrates routinely in patients taking direct oral anticoagulants (DOACs) like apixaban prior to emergency procedures, as advised by the American College of Cardiology 1
Avoid targeting excessively high hemoglobin levels (>100 g/L) through transfusion as this may increase rebleeding risk, as cautioned by the American College of Cardiology and the American Heart Association 1
Remember that a negative nasogastric aspirate does not rule out UGIB (3-16% of patients with UGIB may have a negative aspirate), as noted by the American Gastroenterological Association and the American College of Radiology 3