Red Flags
- Haemodynamic instability with active GI bleeding on anticoagulation — resuscitate, transfuse, urgent endoscopy; reverse anticoagulation per agent[1]
- Major life-threatening bleed on warfarin (intracranial, ongoing massive haemorrhage) — give 4-factor PCC plus IV vitamin K; do NOT give FFP first-line[1]
- DOAC-associated major bleeding — specific reversal: idarucizumab for dabigatran, andexanet alfa or 4F-PCC for factor Xa inhibitors[1]
- Recent (within 30 days) coronary stent on dual antiplatelet — interrupting P2Y12 risks stent thrombosis; involve cardiology before stopping[1]
First-line treatment
Interventions
- Endoscopic haemostasis[1]Within 24 h of presentation. Modalities: clips, thermal coagulation, sclerosant or adrenaline injection, banding for varices. Combination therapy preferred over monotherapy
- Restart anticoagulation early[1]Resume warfarin or DOAC within 7 days of haemostasis (often within 48–72 h) to balance re-bleeding vs thromboembolism. AF without mechanical valve does not need bridging
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Aspirin (continue)[1] | Antiplatelet (secondary prevention) | Continue 75–100 mg PO daily during acute bleed if used for secondary CV prevention; if interrupted, resume on day haemostasis is confirmed at endoscopy | — | ACG-CAG suggests AGAINST routine interruption of cardiac aspirin during acute GI bleed; benefits exceed re-bleed risk |
| Clopidogrel or ticagrelor (interrupt selectively)[1] | P2Y12 inhibitor | Hold during acute bleed if dual antiplatelet not protecting recent stent; involve cardiology if stent <30 days | — | Resume as soon as haemostasis achieved; bridge with aspirin alone if P2Y12 must be paused after recent stent |
| 4-factor prothrombin complex concentrate (4F-PCC)[1] | Coagulation factor concentrate | 25–50 IU/kg IV (max 5000 IU); INR-guided per local protocol | — | Preferred over FFP for warfarin reversal in major bleeding; rapid INR correction. Co-administer IV vitamin K 10 mg |
| Idarucizumab[1] | Dabigatran-specific reversal antibody fragment | 5 g IV (two 2.5 g doses given <15 min apart) | — | Use for dabigatran-associated life-threatening bleeding only |
| Pantoprazole IV[1] | Proton pump inhibitor | 80 mg IV bolus then 8 mg/h infusion for 72 h post high-risk endoscopic stigmata; oral 40 mg BD if low-risk lesion | — | Empirical PPI before endoscopy in upper GI bleed; reduces re-bleed in high-risk ulcers post-endoscopic therapy |
Aspirin (continue)[1]
Antiplatelet (secondary prevention)
- Adult
- Continue 75–100 mg PO daily during acute bleed if used for secondary CV prevention; if interrupted, resume on day haemostasis is confirmed at endoscopy
- Paediatric
- —
ACG-CAG suggests AGAINST routine interruption of cardiac aspirin during acute GI bleed; benefits exceed re-bleed risk
Clopidogrel or ticagrelor (interrupt selectively)[1]
P2Y12 inhibitor
- Adult
- Hold during acute bleed if dual antiplatelet not protecting recent stent; involve cardiology if stent <30 days
- Paediatric
- —
Resume as soon as haemostasis achieved; bridge with aspirin alone if P2Y12 must be paused after recent stent
4-factor prothrombin complex concentrate (4F-PCC)[1]
Coagulation factor concentrate
- Adult
- 25–50 IU/kg IV (max 5000 IU); INR-guided per local protocol
- Paediatric
- —
Preferred over FFP for warfarin reversal in major bleeding; rapid INR correction. Co-administer IV vitamin K 10 mg
Idarucizumab[1]
Dabigatran-specific reversal antibody fragment
- Adult
- 5 g IV (two 2.5 g doses given <15 min apart)
- Paediatric
- —
Use for dabigatran-associated life-threatening bleeding only
Pantoprazole IV[1]
Proton pump inhibitor
- Adult
- 80 mg IV bolus then 8 mg/h infusion for 72 h post high-risk endoscopic stigmata; oral 40 mg BD if low-risk lesion
- Paediatric
- —
Empirical PPI before endoscopy in upper GI bleed; reduces re-bleed in high-risk ulcers post-endoscopic therapy
Safety-net
- Black tarry stools, vomiting fresh blood or coffee grounds, sudden weakness or fainting — call emergency services immediately[1]
- Do not stop your blood thinner (aspirin, clopidogrel, warfarin, DOAC) on your own — sudden interruption can cause stroke or stent clot. Always talk to your clinician first[1]
- After a GI bleed, you will likely restart blood thinners within a week — the risk of clotting from holding them is generally higher than the risk of re-bleeding[1]
Referral criteria
- Haemodynamic instability or massive haemorrhageEmergency department; activate massive transfusion protocol; urgent endoscopy[1]
- Major bleed on DOAC requiring specific reversalEmergency department for idarucizumab (dabigatran) or andexanet alfa / 4F-PCC (Xa inhibitors)[1]
- GI bleed within 30 days of coronary stent placementCardiology AND gastroenterology joint decision before any antiplatelet interruption[1]
- Recurrent or refractory GI bleeding despite endoscopy and PPIInterventional radiology for arterial embolisation or surgery[1]
Clinical summary
Management of acute GI bleeding and peri-endoscopic care for patients on antiplatelets or anticoagulants — when to hold, when to reverse, when to resume.