C H A P T E R

29

Acute Gastrointestinal
Bleeding
Jorge A. Soto and Stephan W. Anderson
ETIOLOGY
The causes of upper gastrointestinal bleeding include
esophageal or gastric varices, Mallory-Weiss tears, gastritis, and gastric or duodenal ulcers. Common causes of
lower gastrointestinal tract bleeding include colonic
diverticulosis, ischemic and infectious colitis, colonic
neoplasm, benign anorectal disease, arteriovenous malformations, ischemia, and Meckels diverticulum.

PREVALENCE AND EPIDEMIOLOGY

Acute gastrointestinal bleeding is a major clinical problem
and is often classified into upper and lower gastrointestinal categories based on the site of hemorrhage (proximal
or distal to the ligament of Treitz). Any loss of blood
occurring throughout the gastrointestinal tract requires
immediate medical attention. Acute lower gastrointestinal
hemorrhage is a common cause of hospital admission,
with significant associated morbidity and mortality. Rapid
stabilization of and therapy for patients with acute gastrointestinal bleeding is critical, because the mortality rate is
reported to be up to 20% in cases of upper gastrointestinal
hemorrhage, depending on the cause.1 Mortality in patients
with acute lower gastrointestinal bleeding is also reported
to approach 20%.2

CLINICAL PRESENTATION
Patients with upper gastrointestinal hemorrhage present
clinically with hematemesis, hematochezia, or melena.
Patients with acute lower gastrointestinal hemorrhage
report melena or hematochezia. When hematochezia
occurs from an upper tract source, the acute blood loss
can be estimated at greater than 1000mL. The signs and
symptoms are somewhat dependent on the underlying
cause. Abdominal pain and diarrhea may be associated
with infectious and inflammatory colitis. When severe,
gastrointestinal hemorrhage may result in hemodynamic
202

instability and shock. Importantly, the amount of blood

passed in vomitus or stool does not serve as a reliable
indicator of the severity of the event, because large
amounts of blood can be sequestered in the intestines.
In addition to the total amount of blood lost, the rate
of bleeding and the overall health of the patient are other
factors determining the clinical presentation and the need
for emergent intervention. Healthy patients have a tremendous capacity to compensate for acute blood losses.
In young individuals with no cardiovascular disease, up
to 2 units of blood can be lost with minimal or no hemodynamic changes. Blood flow can be diverted from the
skin, splanchnic circulation, and kidneys to maintain perfusion of essential organs such as the brain and heart.
Hypotension and tachycardia indicate a larger volume of
blood loss, whereas confusion and oliguria develop when
bleeding loss reaches 3 to 4 units. Finally, although there
is usually a rush to intervene, up to 75% or 80% of the
patients will experience spontaneous cessation of bleeding before any therapy is initiated.

PATHOPHYSIOLOGY
The pathophysiology of gastrointestinal hemorrhage
depends on the underlying cause. In considering the
common causes of upper gastrointestinal hemorrhage,
peptic ulcer disease results in a defect in the gastroduodenal mucosa with eventual exposure and damage to the
underlying arteries, including arteritis, aneurysmal dilatation, and eventual rupture and hemorrhage.3 The larger
the underlying, ruptured vessel, the more significant the
hemorrhage becomes. Mallory-Weiss tears result spontaneously from the marked increase in intraluminal pressures associated with retching and are associated with the
presence of a hiatal hernia.4 Linear tears within the mucosa
of the distal esophagus, cardioesophageal junction, or
cardia result in injury to the underlying vasculature with
subsequent hemorrhage. In patients with varices, increasing hepatic venous pressure gradients result in enlarged

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C H A P T E R

varices and the increased risk of rupture and hemorrhage.

Additionally, the concurrent presence of a bacterial infection is known to increase the risk of variceal hemorrhage,
possibly by decreasing hemostatic function and the presence of systemic endotoxins.5
Diverticular hemorrhage results from rupture of the
vasa recta at the dome of the diverticulum.6 These vessels
have been shown to have eccentric intimal thickening
with asymmetric rupture, suggesting that trauma to these
vessels results in intimal proliferation and scarring, leading
to subsequent rupture and hemorrhage. Angiodysplasia is
typically located within the lower gastrointestinal tract,
specifically the right colon. Although the pathophysiology
is incompletely understood, angiodysplastic lesions are
thought to be acquired through the degenerative process
of aging.7

IMAGING

Radiography
Abdominal radiographs have very limited clinical utility
in patients with acute gastrointestinal bleeding. Clinical
criteria including a history of lung disease and abnormal
pulmonary findings on physical examination may be
useful in selecting a subset of patients with acute gastrointestinal bleeding to receive chest radiographs on admission.8 Abdominal radiographs have been shown not to
affect clinical outcomes or management decisions in
patients admitted to an intensive care unit with gastrointestinal hemorrhage.9

CT
Recently, CT has been shown to have a high diagnostic
accuracy in both the detection and the localization of
massive gastrointestinal bleeding (Fig. 29-1).10-13 Optimal
results necessitate the distention of the bowel with a contrast agent with neutral attenuation, such as water or low-

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l Acute Gastrointestinal Bleeding

203

density barium suspensions (Fig. 29-2). Both unenhanced

and arterial-phase intravenous contrast-enhanced acquisitions should be acquired. CT diagnosis relies on the visualization of an area of active arterial contrast extravasation.
In the majority of cases, CT may diagnose the underlying
cause of acute hemorrhage, such as in the case of small
bowel or colonic neoplasms.10,12,13 The efficiency and ease
of acquisition as well as reported diagnostic accuracies of
multidetector CT in the evaluation of acute gastrointestinal bleeding make this a promising first-line imaging
modality.

Nuclear Medicine
Both technetium-99m (99mTc)labeled red blood cells and
99m
Tc sulfur colloid are applied in the evaluation of acute
gastrointestinal hemorrhage.14 However, 99mTc-labeled red
blood cells offer the possibility for delayed imaging in
cases of intermittent bleeding. The use of nuclear scintigraphy has been demonstrated to be sensitive in the detection and accurate in the localization of the source of acute
gastrointestinal hemorrhage. The diagnosis of gastrointestinal bleeding on nuclear scintigraphy depends on the
visualization of an area of tracer localization that persists
and should be seen to move through the lumen of the
bowel secondary to peristalsis. Both antegrade and retrograde transit is observed, but localization is dependent on
the initial area of visualization (Fig. 29-3). The localization
of the site of bleeding has been shown to be highly accurate with nuclear scintigraphy and clinically useful in
guiding subsequent transcatheter therapies or surgical
resection.15

Imaging Algorithm
There is no consensus regarding the initial imaging evaluation of patients presenting with acute gastrointestinal
bleeding. Endoscopy, 99mTc-labeled red blood cell scintigraphy, CT, and conventional mesenteric angiography are

n FIGURE 29-1 A, Axial unenhanced CT image reveals diffuse hyperattenuation throughout the bowel lumen. The lack of intravenous use of a
contrast agent precludes the localization of the hemorrhage; however, CT demonstrates its significant volume. B, Coronal reformatted axial CT image
reveals the extent of intraluminal hemorrhage as evidenced by hyperattenuation throughout the bowel. C, 99mTc-labeled red blood cell scan localizes
the area of active hemorrhage to the duodenum (arrow). The patients acute hemorrhage, which was related to underlying peptic ulcer disease, was
successfully treated with coil embolization.

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204

P A R T T W O l Nontraumatic Acute Abdomen

n FIGURE 29-2 A, Axial CT image reveals a punctuate area of hyperattenuation in the distal ileum consistent with active extravasation (arrow). This
image demonstrates the importance of adequate oral preparation with a neutral attenuation contrast agent to optimize the contrast between active
hemorrhage and the bowel lumen. B, Coronal reformatted axial CT image demonstrates the area of active hemorrhage within the distal ileum (arrow).
C, 99mTc-labeled red blood cell scan reveals ongoing hemorrhage in the distal ileum (arrow). The patient underwent digital subtraction angiography
twice without evidence of ongoing hemorrhage before receiving definitive partial small bowel resection.

n FIGURE 29-3 A, 99mTc-labeled

red blood cell scan reveals an initial
area of active hemorrhage in the
proximal sigmoid colon (arrow).
B, Note ongoing hemorrhage
with retrograde transit within
the descending colon (arrows).
Localization is dependent on initial
visualization and in this case is
secondary to sigmoid diverticulosis.

TABLE 29-1 Accuracy, Limitations, and Pitfalls of the Modalities Used in Imaging of Acute Gastrointestinal Bleeding
Modality

Accuracy

Limitations

Pitfalls

CT

>95% for localization

Nuclear medicine

>90% for localization

>95% for localization

Hypervascular gastrointestinal
neoplasms
Vascular organs interfere with
interpretation.

Angiography

Ionizing radiation exposure,

intermittent bleeding
Poor localization of bleeding
site
Rate of bleeding, intermittent
bleeding

all successfully applied, depending on the given scenario

(Table 29-1).10-17 Upper endoscopy is very valuable in
patients with upper gastrointestinal bleeding to determine
the exact source and cause and as a means of therapy in
many instances. For patients with hematochezia and/or
unclear sources of bleeding, nuclear scintigraphy is a valuable technique, although CT enterography is gaining
acceptance in this situation as well. In cases of severe,

massive upper or lower gastrointestinal hemorrhage,

catheter angiography of the mesenteric circulation is
often necessary as a means for catheter-directed therapy,
such as injection of vasopressin and, more currently, for
superselective embolization techniques that have been
shown to be an effective method of treatment (Fig. 29-4).
In general, it is believed that a critical rate of hemorrhage
of approximately 0.5mL/min is necessary for a bleeding

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C H A P T E R

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n FIGURE 29-4 A, Axial CT image shows a punctuate area of hyperattenuation in the ascending colon, consistent with active hemorrhage (arrow).
B, Coronal reformatted axial CT image demonstrates the area of active hemorrhage within the ascending colon (arrow). C, 99mTc-labeled red blood
cell scan reveals active hemorrhage with initial localization to the ascending colon, as on CT (arrow). D, Note the ongoing active hemorrhage with
antegrade transit into the transverse, descending, and sigmoid colon (arrows). E, Digital subtraction angiogram shows an area of active extravasation
within the ascending colon (arrow) that was subsequently successfully treated with coil embolization.

focus to be detected with angiography, whereas 0.05mL/

min can be detected with state of the art scintigraphic
techniques.18
An algorithm for the evaluation of acute gastrointestinal
bleeding is presented in Figure 29-5.

Algorithm for Spontaneous Gastrointestinal Hemorrhage

Upper GI source

Endoscopy

Classic Signs
n

On CT, the area of gastrointestinal hemorrhage is identified

as a contrast blush seen on the contrast-enhanced images
within the lumen of the gastrointestinal tract.
n On nuclear scintigraphy, bleeding is seen as a focus of activity that either increases in intensity or changes in location
over time secondary to peristalsis.
n On catheter angiography, active hemorrhage is seen as a
focus of active extravasation of contrast-enhanced blood
that persists and may grow over time and is not washed out
on delayed images.

Lower GI source/unclear

Nuclear scintigraphy

Diagnosis  therapy

CT enterography

Catheter angiography

Therapy
n FIGURE 29-5 Algorithm for evaluation of spontaneous

gastrointestinal hemorrhage.

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206

P A R T T W O l Nontraumatic Acute Abdomen

DIFFERENTIAL DIAGNOSIS
Differential considerations from clinical data depend on
the severity of the gastrointestinal bleeding and its underlying etiology. In the presence of hematemesis, melena,
or hematochezia, gastrointestinal hemorrhage, by definition, is the diagnosis. However, if these signs are not
evident and the patient is presenting with syncope or
signs of hypotension, myriad differential considerations
may be entertained. This would include sources of hemorrhage elsewhere, including intra-abdominal, retroperitoneal, or intramuscular locations. However, patients with
acute gastrointestinal bleeding typically present with
hematemesis, melena, or hematochezia, allowing for the
diagnosis to be made.
Using CT, the differential considerations of a contrast
blush within the lumen of the gastrointestinal tract are
limited. Potential considerations include small, hypervascular tumors, such as neuroendocrine tumors. A second
contrast-enhanced phase of imaging would potentially be
useful in differentiating active arterial extravasation from
a hypervascular mass lesion. On nuclear scintigraphy,
abnormal accumulations of the radiotracer potentially representing foci of hemorrhage must be differentiated from
other sources of activity such as ectopic or accessory
spleens, uterine leiomyomas, or a vascular mass lesion,
among other potential sources.19

Invasive, nonsurgical techniques include transcatheterdirected therapies and endoscopy. Currently, transcatheter-directed embolotherapy is commonly applied in cases
of acute gastrointestinal hemorrhage.17,20 Various forms of
therapy are also available with endoscopy, including
sclerotherapy, laser coagulation, and banding.16,21,22

Surgical Treatment
Although conservative, endoscopic and transcatheter
means of therapy are preferred, emergent surgery is necessary for patients who do not respond or in whom bleeding recurs rapidly after several attempts of control with
less-invasive methods. Morbidity and mortality rates are
high in these patients.

What the Referring Physician Needs to Know

n

Is there a source of active bleeding?

What is the location of the active bleeding?
n What is the cause of bleeding?
n Is the patient a candidate for transcatheter therapy?
n

KEY POINTS
TREATMENT

Medical Treatment
Patients with acute gastrointestinal hemorrhage should be
admitted to the hospital for observation and evaluation.
Initial resuscitation includes correction of volume loss
with crystalloids and blood products. Continuous monitoring with electrocardiographic lead placement, pulse
oximeters, and automatic blood pressure cuffs is advised.

S U G G E S T E D

Sources of acute bleeding should be separated into those

affecting the upper and lower gastrointestinal tract, using
the ligament of Treitz as the boundary.
n After initial resuscitation and stabilization, diagnostic
methods commonly used include upper and lower en
doscopy, nuclear scintigraphy, catheter angiography,
and, more recently, CT.
n Many patients can be successfully treated with transcatheter interventional techniques.

R E A D I N G S

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acute GI haemorrhage. Clin Radiol 2007;62:938-949.
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Howarth DM. The role of nuclear medicine in the detection of acute

gastrointestinal bleeding. Semin Nucl Med 2006;36:133-146.
Laing CJ, Tobias T, Rosenblum DI, et al. Acute gastrointestinal bleeding:
emerging role of multidetector CT angiography and review of current
imaging techniques. RadioGraphics 2007;27:1055-1070.

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minal radiography in patients with gastrointestinal hemorrhage
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