GASTROINTESTINAL BLEEDING • Small and large intestines have no nerve endings
• can come from any of the areas in the digestive
tract.
• from the mouth to the anus
• signs of bleeding in the digestive tract depend
where it is and how much bleeding there is.
• malaking factor sa amount of bleeding is kung
anong blood vessel yung affected.
• Artery - more massive bleeding
• Manifestations will depend here
• GI bleeding is a symptom of a disease or a
condition, rather than a disease or condition itself.
• When pxs come into the hospital with GI bleeding
assessment is important. Determine the root cause
why the px is bleeding internally.
• Overt
bleeding can be recognized immediately unlike
occult bleeding.
• the amount of bleeding can be so small that only a
laboratory test can find it.
Esophageal Varices
• varicosities/dilation ng mga blood vessels in the
esophageal are. Associated with portal
hypertension secondary to liver cirrhosis.
• A result of backflow of blood from hepatic
circulation backward to the GI system because of
obstruction or inflammation or cirrhosis.
Malory-Wise tear
• Minute tear in the esophagaus
• Commonly associated with strenuous coughing or
vomiting episodes (induced vomiting)
Gastritis
• Inflammation of the lining of the gastric mucosa
• Continuous exposure to insult will lead to ulcer >
perforation > tendency for bleeding episodes >
hemorrhagic gastritis - namumula lang muna but
later on can cause bleeding.
Ischemic bowel disease
• Ischemia in the bowel.
A. Visibility of bleeding:
for us to determine kung nagkakaroon na ng
pagkabulok.
• Compression/alteration in surrounding
structures/blood vessels will give a hint to the px.
• Possibility of pagkabulok of bowel.
• Ischemic portion can slough off and can cause
bleeding.
Intussusception
• Telescoping of the small intestine into another part
of the small intestine.
• Literally like a telescope.
• Area na nagtelescope will be compressed and in
the long run can necrotise and can slough off to
cause bleeding; or it can also cause an obstruction.
Meckel diverticulum
• Diverticula - out pouching
• Meckel diverticulum - occurs in the large intestine.
• Diverticulosis - small intestine
Increase build up of intraluminal pressure.
• Congenital defect that is said na karugtong ng
umbilcal cord ng isang neonate.
• Diverticulum can rupture and can cause bleeding
lalo na kapag may increaseed build up of pressure.
• Food particles na Hindi na-absorb or fecal material
can accumulate sa out pouches > can cause
inflammation > can cause rupture > can cause
bleeding
Angiodysplasia
• Angio - blood vessel
• Dysplasia - alteration of normal characteristic and
appearance of blood vessel
• Increased BP can cause rupture.
Colonic cancer and rectosigmoid carcinoma
• Can cause lower GI bleeding.
• Cancer cell - needs blood supply. They create their
own blood vessel (angiogenesis) - they branch it off
the original blood vessel of the host. These vessels
are thin and can easily rupture > can cause
bleeding.
Inflammatory bowel disease
• Classified into 2 diseases.
• 1. Regional enteritis - affects the small intestine
• 2. Ulcerative colitis - affects primarily the colon
• Condition that promotes excessive diarrhea - some
pxs can manifest bloody diarrhea.
• Exact cause is unknown.
Hemorrhoids
• Most common factor for lower Gi bleeding.
• Like outpouching pero kasama blood vessels.
• Secondary to constipation
• Px can also suffer from anal fissures.
GI BLEEDING CLASSIFICATION
 • Occult bleeding: ulcerative colitis
Bleeding in quantities too small to be (UC) & Crohn
macroscopically observable (requires chemical disease (CD)
- Invasive or
tests or microscopic examination to be detected). inflammatory
Maaring capillaries lang diarrhea -
• Overt (visible) GI bleeding: bacterial
Macroscopically observable bleeding with gastroenteritis,
due to e.g.,
accompanying clinical symptoms. (e.g., anemia, shigella,
tachycardia) enterohemorrha
gic escherichia
B. Degree of bleeding: coli (EHEC)
• Acute GI bleeding: VASCULAR - esophageal varices - Hemorrhoids
Sudden and sever (sometimes) or gastric varices - Ischemia (e.g.,
Acute, massive bleeding - can lead to - Gastric antral ischemic colitis,
hypovolemic shock, and even death; vascular ectasia mesenteric
(“watermelon ischemia)
- Can occur at any age from birth. stomach”) - Arteriovenous
- Mas nakakatakot kapag very young or very - Dieulafoy lesion: malformation
old ang px. minor mucosal - Rectal varices
• Chronic GI bleeding: trauma to an
abnormal
Slight bleeding that can last a long time or may submucosal artery -
come and go aneurysm (usually
Minute GI bleeding; mahirap madetect located in the
Kapag may manifestations na like anemia tsaka proximal stomach)
leads to major
lang mas napapansin bleeding (acute
Prolonged microscopic bleeding - can lead to UGIB)
loss of iron, causing anemia.
- anglodysplasia: a
common
C. Site of bleeding is divided into: degenerative
• Upper GI bleeding - located between the mouth disorder of GI
and the upper part of the small intestine. vessels (mostly
venous) that can
~70% - 80% of GI hemorrhages
cause GI bleeding
The source of the bleeding is proximal to the in the stomach,
ligament of Treitz (suspensory muscle of the duodenum,
duodenum). jejunum, and colon.
• Associated with
It is characterized by hematemesis and melena.
age >60 years, von
Hematemesis - pagsuka ng dugo Willebrand disease,
Kapag hindi nasuka it can go down further sa GI aortic stenosis, and
tract and then lumabas as melena (or black tarry ESRD
• Manifests with
stools) because na-digest na yung blood along
episodic bleeding
the GI tract. (hemtochezia) that
About half of cases are due to PUD ceases
Esophagitis and erosive disease is the next most spontaneously
(>90% of cases)
common causes (also ulcers)
• Diagnosis usually
• Lower GI bleeding - located between the upper part requires
of the small intestine and the anus. anglography.
• ~20% - 30% of all GI hemorrhages • Lesions are usually
multiple tortuous
• The source of the bleeding is distal to the
dilated vessels
ligament of Treitz, usually in the colon. Most
• Hematochezia - passage of blood in the stool. commonly
• It may be indicated by passage of red blood located in the
discharge per rectum, especially in the absence right-sided colon
(~75%).
of hematemesis.
• The most common cause is hemorrhoids.

GI BLEEDING ETIOLOGIES • Crohn disease and inflammatory diarrhea - usually

ETIOLOGY UGIB LGIB
manifest bloody diarrhea.
• Ectasia - dilation of blood vessels
INFLAMMATO - PUD (`30% of - diverticulosis • Characteristic that signifies vascular ectasia is the
RY/ EROSIVE cases) (~30% of watermelon stomach (yung parang may stripes)
- Esophagitis cases)
- Erosive gastritis - Inflammatory Lining of the stomach is may parts na mapula tas
and/or duodenitis bowel disease may parts na pale.
(IBD) - i.e.,
• Dieulafoy lesion > aneurysm > can lead to mahor up in the relates to
bleeding stomach sexual acts
• Aneurysm - permanent dilation of an artery; arteries that involves
become weak. objects
• There are different types of aneurysm: inserted in the
Dissecting aneurysm - the different tunica’s ay na- anus)
infiltrate na **Following open or endoscopic surgery (e.g.,
Remember na arteries have high pressure so anastomotic bleeding following a gastric bypass)
kapag bumaba sya in areas na may dilation it can Other  Postal  Anal fissures
cause rupture Causes Hypersensitive
gastropathy –
 Ischemia - Kapag ang isang area ng bowel sa small gastric mucosa
or large intestine ay nabubulok, pwedeng mapull out is inflamed,
yung area na yon na pwedeng reason for bleeding becomes
 Arteriovenous malformation (AVM) edematous and
o Normally: Artery connects to a capillary then dilated blood
tsaka sa vein vessels
o In AVM, there is no capillary. Artery connects  Coagulopathies
directly to a vein,which causes the problem.
o Because the capillary functions as a gradient INCIDENCE
that decreases the pressure.  UGIB 100/100,000
o Therefore, kapag direct ang artery and vein,  LGIB 20/100,000
hinid kakayanin ng walls ng veins ang high o Both are more common in males and elderly.
pressure blood flow ng artery kaya there is  Bleeding from the upper respiratory tract (e.g.,
possibility of rupture, which is common sa mga nocturnal nosebleeds) can be mistaken for GI
may AVM. bleeding because the blood can be swallowed and
 AVM- a congenital defect na walang capillary ang vomited or appear in the stool as melena. Careful
isang patient. examination and history taking is the key to
 Von Willebrand – abnormal blood coagulation. differentiating respiratory sources of bleeding from
 Aortic stenosis – narrowed path/opening of aortic GI ones.
valve
 Angiography – visualization of the blood vessels
with the help of a contrast medium.
 Specifically located in the right-sided colon
PROBABLY, yun yung area ng colon natin na
nagrereceive ng flow ng digested and undigested
food from the ileum na highly fluid pa.

ETIOLOGY UGIB LGIB

Tumors  Esophageal  Colorectal
cancer and/or cancer and/or
gastric anal cancer
carcinoma  Colonic polyps
(grape-like
structures,
predispose to
colon cancer)
Traumatic  Hiatal Hernias  Lower
or  Mallory-Weiss abdominal
Iatrogenic Syndrome (tear trauma -
in the blood Hemorrhoids  Ligament of Treitz – the line to determine if it is an
vessel in the leading to upper or lower GI bleeding.
Esophagus) bleeding COMMON CAUSES OF GI BLEEDING
 Boerhaave  Anorectal Drug-Induced  Corticosteroid
Syndrome trauma (e.g.,
 NSAIDS
(Spontaneous anorectal
avulsion,  Salicylates
Esophageal
rupture) – this is impalement Esophagus  Esophageal varices
secondary to injuries)  Esophagitis
extreme  Anorectal  Mallory-Weiss tear
pressure build avulsion Stomach and Duodenum  Stomach Cancer
  Hemorrhagic gastritis
 PUD RISK ASSESSMENT
 Polyps  PRE-ENDOSCOPY
 Stress-related o All patients with GI bleeding should be risk-
mucosal disease stratified to guide the diagnostic and
Systemic Diseases  Blood dyscrasias therapeutic approach, timing of endoscopy,
(e.g., leukemia, and patient disposition.
aplastic anemia)  LOWER-RISK CLINICAL SCENARIOS
 Renal failure o Occult GI bleeding
- Hard to perform when patient experiences
RISK ASSESSMENT active massive bleeding.
 GI Bleeding is not merely the disease, this is the - Risky on the part of the client
manifestation of underlying conditions. - EGD is not a priority procedure to do.
 It is important to perform risk assessment to - We need to address the bleeding by giving
determine if the patient is at risk for GI bleeding. fluids to replenish or blood transfusion for
 This is usually done of physicians. low hemoglobin or hematocrit levels
ENDOSCOPY o Scant intermittent hematochezia due to
 The best determination of risks is through benign anorectal disease (e.g., hemorrhoid,
endoscopy anal fissure)
o Could be done in the Esophagus, gastro or  HIGHER-RISK CLINICAL SCENARIOS
duodenum. Or sigmoid, recto-sigmoid or o Overt GI bleeding with high-risk features
colonoscopy. - see table below
o Determine where is the source of bleeding, what o Esophageal variceal bleeding
type of bleeding, etc. - Esophageal varices: dilated blood vessels
 Pre-endoscopy on the esophagus. When you perform the
o All patients with GI bleeding should be risk- EGD procedure, there is an increase
stratified to guide the diagnostic and therapeutic likelihood to hit an area of dilated
approach, timing of endoscopy, and patient esophageal varices causing rupture and
disposition. bleeding. Ideally, this procedure is not done
 Lower-risk clinical scenarios when there is suspected esophageal
o Occult GI Bleeding varices.
 First address the bleeding. High-risk features of GI bleeding
o Scant intermittent hematochezia due to benign https://next.amboss.com/us/article/ZS0Zy2#Za9Ba909
anorectal disease (e.g., Hemorrhoids, anal ec46171fc7d61894f4c263065
fissure)
 Higher-risk clinical scenarios Patient Factors  Age >60 years
o Overt GI bleeding with high-risk feature - wala  Chronic comorbidities
kang makikita kapag may massive bleeding and  History of diverticulosis
mas risky or angioectasia (for
o Esophageal variceal bleeding. LGIB)
HIGH-RISK FEATURES OF GI BLEEDING -Ectasia: dilated blood
vessels
Patient factors  Age >60 y/o
- Especially in the GI
 Chronic comorbidities tract, there is a higher
 History of diverticulitis chance of bleeding
or angioectasia (for associated with
LGIB) colonoscopy procedure
 History of an AAA and enema (prior to
graft colonoscopy)
Features Presentation  Hemodynamic  History of an AAA graft
instability - Some patient
 Ongoing bleeding experience dilation of
 Anemia, HVT ≤ 355, abdominal aorta. Pag
coagulopathy, or tumaas/lumaki yung
elevated BUN dilation of blood vessel
 Need to transfuse ≥ 6 (above 5.5 or 6cm in
units of packed RBCs diameter), there is an
Interpretation: >1 feature is associated with a risk of increase likelihood of
severe or recurrent bleeding rupture that may cause
 massive bleeding. g/dL
Repair is necessary ≤ 10 ≤ 10 5
and patient is g/dL g/dL
candidate for AAA Clinical Systemic ≥ 110 mmHg 0
graft) Features Blood 100-109 mmHg 1
Features at  Hemodynamic Pressure 90-99 mmHg 2
presentation instability ≤ 90 mmHg 3
 Ongoing bleeding Additional Heart rate ≤ 1
 Anemia, HCT ≤ 35%, Criteria 200/min
coagulopathy, or Melena at 1
elevated BUN presentation
- in relation in BUN, Syncope at 2
elevation of it may be presentation
caused by active GI Liver disease 2
bleeding due to the - Liver:
blood present in the responsible for
stomach that is producing the
metabolized and clotting factors
digested into urea. - If patient is
 Need to transfuse ≥ 6 bleeding, and her
units of packed RBCs liver function is
Interpretation > 1 feature is associated with a risk of incapable to
severe or recurrent bleeding produce
UGIB scoring systems: coagulating
e.g., the Glasgow-Blatchford score (GBS) factor, further
 Used to guide patient disposition in bleeding episode
hemodynamically stable patients with UGIB. is possible.
 Along with other scoring system it helps estimate: Heart Failure 2
o The likelihood of rebleeding - Heart finds it
- Purpose of creating this scoring system is difficult to
compensate to
for proper categorization.
the decreasing
- GI bleeding is not the disease perse of the
fluid volume or
patient, it is more often a manifestation of an cardiac output
underlying gastrointestinal disorder. that is being
o The need for urgent hemostatic control circulated into the
o Mortality body.
 Scores are directly proportional with risk of Interpretation
rebleeding and need for urgent intervention.  Score 0 low-likelihood of rebleeding or need for
o Score ≥ 7 – associated with a higher urgent intervention.
likelihood of urgent endoscopic intervention  Score ≥ 1 higher likelihood of rebleeding and or
and mortality. need for urgent intervention.
- Urgent endoscopic intervention: kailangang
susunugin yung blood vessels to create a  Critical assessment is needed – who is more likely is
tamponade for the bleeding to stop. at risk to develop GI bleeding.
Glasgow-Blatchford score  Detailed History must also be done.
Parameters Findings  But if patient is suffering from massive bleeding,
Laboratory BUN ≤ 18.2 mg/dL 1 withhold the history taking, focus to the assessment
Features 18.2 mg/dL – 2 and address the current problem/physiological
22.3 g/dL status of the patient. Avoid the occurrence of
22.4 mg/dL – 3 hypovolemic shock.
27.9 mg/dL LGIB scoring systems:
28 mg/dL – 69.9 4 e.g., the Oakland score.
mg/dL  This externally validated risk score based on
5 o Age
Hemoglobin Male Female o Sex
≥ 13 ≥ 12 0 o Prior admissions for LGIB
g/dL g/dL
o Vital signs
12-13 10-12 1
o DRE findings
g/dL g/dL
10-12 N/A 3 o Hemoglobin at admission
 It can help identify patients at low risk of poor  Age
outcomes who can be safely managed as ≤ 40 0
outpatients. 40-69 1
Variables comprising the Oakland score ≥ 70 2
Predictor Score component value  Gender
 Age Female 0
≤ 40 0 Male 1
40-69 1  Previous LGIB
≥ 70 2 admission
 Gender No 0
Female 0 Yes 1
Male 1  DRE findings
 Previous LGIB No blood 0
admission Blood 1
No 0  Heart Rate
Yes 1 ≤ 70 0
 DRE findings 70-89 1
No blood 0 90-109 2
Blood 1 ≥ 110 3
 Heart Rate  Systolic blood
≤ 70 0 pressure
70-89 1 < 90 5
90-109 2 90-119 4
≥ 110 3 120-129 3
 Systolic blood 130-159 2
pressure ≥ 160 0
< 90 5  Hemoglobin
90-119 4 < 70 22
120-129 3 70-89 17
130-159 2 90-109 13
≥ 160 0 110-129 8
 Hemoglobin 130-159 4
< 70 22 ≥ 170 0
70-89 17 Patients scoring ≤ 8, with no other indications for
90-109 13 hospital admission are suitable for immediate
110-129 8 discharge from Accident and Emergency and
130-159 4 outpatient investigation. DRE, digital rectal
≥ 170 0 examination: LGIB, lower gastrointestinal bleeding.
Patients scoring ≤ 8, with no other indications for
hospital admission are suitable for immediate  DRE – Digital Rectal Exam
discharge from Accident and Emergency and  Kapag lower ang risk ng patient, the Dr may perform
outpatient investigation. DRE, digital rectal further assessment like colonoscopy
examination: LGIB, lower gastrointestinal bleeding.
FORREST CLASSIFICATION OF BLEEDING PEPTIC
LGIB scoring systems: ULCERS
e.g., the Oakland score.
 This externally validated risk score based on
o Age
o Sex
o Prior admissions for LGIB
o Vital signs
o DRE findings
o Hemoglobin at admission
 It can help identify patients at low risk of poor
outcomes who can be safely managed as
outpatients.
Variables comprising the Oakland score
Predictor Score component value
 Ia – spurting arterial haemorrhage, damaged bleeding: of blood from
integrity of mucosal lining maroon, the upper GI
 Ib – mas malakas ang bleeding episode jelly-like tract may also
 IIa – may visible vessel na if exposed to higher traces of result in
blood in hematochezia
insult, pwedeng matuklap ang outermost layer ng
stools
blood vessel that may cause spurting arterial or
- Rectal
active oozing haemorrhage bleeding:
 IIb – Ulcer with an adherent clot, shows that streaks of
nagkaroon ng recent PUD fresh blood
 IIc – Flat ulcer with a dark base (covered with on stools
hematin) (hematin – greenish yellow covering on  Both melena and hematochezia can be caused by
top of ulcer) either UGIB or LGIB.
III – flat ulcer base (no active haemorrhage)  Unexplained iron deficiency anemia (in men or
postmenopausal women) should raise suspicion for
COLONOSCOPY GI bleeding.
 Inpatient treatment is recommended if there are
UPPER GI BLEEDING
features requiring intervention or associated with
rebleeding  Bright red or coffee ground vomitus (hematesis)
 Melena
UPPER ENDOSCOPY  Decreased BP
 The Forrest classification is commonly used to  Increased HR
determine the need for hemostatic interventions  Weak peripheral pulses
during the procedure and can help guide disposition  Acute confusion (in older adults)
by predicting the risk of rebleeding  Vertigo
 Dizziness or light-headedness
GASTROINTESTINAL BLEEDING MANIFESTATIONS  Syncope (loss of consciousness)
 Anemia due to chronic blood loss  Decreased haemoglobin and hematocrit
o Acute haemorrhage with significant blood loss
 Signs of circulatory insufficiency or hypovolemic GI BLEEDING MANIFESTATION
shock  Cannot be generalized kasi pwedeng ,magresult
o Tachycardia, hypotension (dizziness, collapse, from different area yung bleeding sa lower GI.
shock) LOWER GI BLEEDING
o Altered mental status IBD
Features of overt GI bleeding 
Young patients may not present with abdominal
Description Cause pain, rectal bleeding, diarrhea, and mucus
Hematemesis Vomiting blood, Most commonly discharge.
may be red or due to bleeding ANGIODYSPLASTIC LESIONS
coffee-ground in in the upper GI  Elderly patients with atherosclerotic heart
appearance tract disease may not present with intermittent LGIB
(esophagus, and syncope.
stomach)
 Blood vessels in the colon become tortuous.
Melena Black tarry Most commonly
ISCHEMIC COLITIS
stool, with due to bleeding
strong offensive in the upper GI  Elderly patients presenting with abdominal pain,
odor tract rectal bleeding and diarrhea.
PERIANAL PATHOLOGY (such as anal fissure or
Can also occur hemorrhoidal bleeding)
in bleeding from  Stools are streaked with blood.
the small bowel  Patients has perinatal pain and
or the right  (+) blood drops on the toilet paper or in the toilet
colon
bowl.
Hematochezia The passage of Most commonly
MASSIVE LGBI
bright red due to bleeding
(fresh) blood in the lower GI  A life-threatening condition in which patient
through the tract (distal present with:
anus (with or colon)  A SBP below 90 mm Hg and
without stool)  A Hgb level of 6 g/dl or less
- Colonic Rapid passage  Patient manifest signs of hypovolemic shock
  Affected patients are usually: palpitation ischemia
o 65 years and older Rectal exam Bloody or Check the anal
o w/ multiple medical problems &, melanotic stool fissure,
o are at risk of death from acute hemorrhoids,
masses and
hemorrhage or its complications.
gross blood on
 The passage of maroon stool or bright red blood stool exam
from the rectum is usually indicative of massive
lower GI hemorrhage. CHARACTERISTIC OF BLOOD
BRIGTH RED
PRESENTATION OF LGIB DEPENDING ON
 Vomited from high in esophagus (hematemesis):
ETIOLOGY
from rectum or distal colon (coating stool).
INFECTIOUS OR NONINFECTIOUS (IDIOPATHIC)
COLITIS Hematochezia
o Left -sided bleeding of the colon
 A young patient may present with fever,
dehydration, abdominal cramps, and o If the bleeding is brisk and massive – it
hematochezia. maybe evident also in patients with
 Common sa mga infectious conditions leading to UGIB and those with right-sided colonic
colitis ay mga inflammatory bowel diseases. bleeding.
MIXED WITH DARK RED
 Noninfectious have unknown cause.
 Signs and symptoms are secondary to  Higher up in colon and small intestine: mixed
excessive blood or stool excreted. with stool.
DIVERTICULAR BLEEDING OR ANGIODYSPLASIA o Right-sided bleeding of the colon
SHADES OF BLACK (COFFEE GROUND)
 Older patient may have minimal symptoms and
present with painless bleeding and  Esophagus, stomach, & duodenum; vomitus
o Mild and intermittent LGIB (if due to from these areas
angiodysplasia)  It represents that there is digestion of blood from
o Moderate or severe LGBI (if due to GI tract.
TARRY STOOL (MELENA)
diverticula-related bleeding)
IMPORTANT EXAM FINDING  Occurs in patients who accumulates excessive
blood in the stomach.
Physical exam Exam Finding Significance o Maybe present with cecal bleeding
component NO distinct method exists for determining the anatomic
Resting HR >90/min Loss of <15% source of bleeding based solely on stool color.
tachycardia total blood Stool color is not a confirmatory test that there is GI
volume bleeding. Therefore, still assess the patient because
Orthostatic Decrease in Loss of >15% signs and symptoms vary.
hypotension SBP ≥20 mm total blood
Hg or DPB ≥10 volume
mm Hg from
supine to
standing
position
Supine Supine BP ≤ Loss of ≥40%
hypotension 80/60 mm Hg total blood
volume
Abdominal Rebound Peritoneal signs
exam involuntary may indicate
guarding, perforated
extreme pain to viscus or bowel
ESOPHAGUS
 Bright red blood via vomitus and hematochezia in
stool if there is heavy bleeding.
 Coffee ground vomitus and the stool is melena
and positive fecal occult blood if light bleeding.
STOMACH
 Blood clots and mixture of bright and dark red
blood vomitus, hematochezia may occur in stool
for heavy bleeding.
 The same with esophagus for light bleeding.
DUODENUM
 More blood clots in the vomitus bright to dark red,
stool is a mixture of dark red and black blood for
heavy bleeding.
 The same with esophagus for light bleeding.
COLON
 No vomitus, stool fluctuate from bright red to dark
red for heavy bleeding.
 No vomitus, on stool exam there are blood clots,
positive fecal occult blood for light bleeding.
SIGMOID
 No vomitus, bright red blood in the stool for heavy
bleeding.
 No vomitus, on stool exam there are blood clots,
positive fecal occult blood for light bleeding.
RECTUM
 No vomitus, bright red blood in the stool for heavy
bleeding.
 No vomitus, on stool exam there are streaks on
stool, positive fecal occult blood for light
bleeding.
Gastrointestinal bleeding Clinical features of
gastrointestinal (GI) bleeding, including hematemesis,
melena, and hematochezia, vary depending on source
and volume bleeding.
GI BLEEDING DIAGNOSTIC/LABORATORY TESTS
 It is not difficult to diagnose bleeding, but it may
be difficult to locate the source of bleeding.
 It is easier to address the situation if the bleeding
location or root cause is known, and this is a
challenge to the health practitioner to identify
where the bleeding is.
HISTORY
 Change in bowel pattern, presence of pain or
tenderness, recent intake of food and what kind,
alcohol consumption, such as aspirin or steroids.
 Focus assessment ang ginagawa for emergency
na dinudugo ang patient kapag dumating sa
hospital to prevent the patient from suffering sa
hypovolemic shock
STOOL EXAM
 To detect occult bleeding
 Occult blood: diverticular disease, esophagitis,
gastritis, esophageal varices, anal fissure,
hemorrhoids, infectious diarrhea, inflammatory
bowel disease, polyps, tumors, ulcers, Mallory-
Weiss tears.
 These conditions are the possible etiology or risk
factor for the development or manifestation that
leads to GI bleeding.
GI BLEEDING DIAGNOSTIC/LABORATORY TEST
BLOOD TEST – to detect whether you have anemia or
bleeding disorders
 COMPLETE BLOOD COUNT – low Hgb
indicates anemia; Thrombocytopenia can cause
GI bleeding
o To check if mababa na ang
hemoglobin and platelet count.
Normal response of our body kapag
may bleeding, may platelet
aggregation so there is an increased
likelihood na bumaba ang platelet
count.
 COAGULATION STUDIES – a series of serum
tests that evaluate for abnormal blood clotting
o Specifically for patients having GI
bleeding caused by coagulopathy
 BLOOD TYPE AND CROSSMATCHING –
should be obtained promptly in patients with
ongoing GI bleeding and/or hemodynamic
instability at presentation
o In preparation for having blood
transfusion, lalo na kapag may
massive bleeding
 BUN LEVEL – extensive bleeding into the
gastrointestinal (GI) tract will also cause an
elevated BUN because digested blood is a
source of urea.
o Tumataas ang BUN kasi nada-digest
ng stomach yung blood accumulating
in the GI tract.
 LIVER FUNCTION TESTS (LIVER
CHEMISTRIES) – a group of laboratory test that
serve as parameters of hepatocellular damage,
cholestasis, and hepatic synthesis.
o Liver is also functioning in
manufacturing the clotting factors
o Impairment of the liver leads to
further bleeding episodes.
- Anemia, low hematocrit, coagulopathy, and
elevated BUN at presentation are signs of GI
bleeding
- An elevated BUN to creatinine ratio in a
patient with hematochezia suggests a brisk
UGIB
 o Normally if there is an elevation of
metabolic waste, creatinine is being
observed in relation with renal
functioning.
o But in this condition, ang tinitingnan ay GI
bleeding na cause ng digestion ng RBC
and na ang by product ay urea, hindi
creatinine, kaya BUN ang tataas.
NASOGASTRIC ASPIRATES (NG ASPIRATE) – this test
is not routinely recommended other than as adjunct in
patients with hematochezia with only moderate probability
of UGIB as the source
It is not routinely recommended because it will further
create trauma in the lining of the mucus membrane 
further bleeding episode. Mas preferred ang EGD
 Procedure: Instill 200-300 mL of warm
isotonic saline via NG tube, then aspirate
gastric contents for inspection
 Findings:
o Positive: Bright red blood or coffee-
grounds output; active UGIB confirmed
o Inconclusive: Non-bloody and non-
bilious
o Negative: Non-bloody and bilious; active
UGIB less likely
- In patients with suspected UGIB, nasogastric
aspiration is poorly sensitive as ~15% of
patients with active UGIB can have a false
negative
ENDOSCOPY – to detect and see if and where you have
GI bleeding and the cause of the bleeding
Cannot be performed kapag may massive bleeding ang
patient, it should be addressed first by giving
vasoconstrictors, fluid resuscitation or blood transfusion to
stabilize the hemodynamic status before performing any
diagnostic procedure.
 EGD (assess the upper GI tract)
o Source of GI bleeding identified (positive
EGD): Attempt endoscopic hemostasis.
o Source of GI bleeding not identified
(negative or nondiagnostic EGD)
 Hemodynamically stable patients
with hematochezia or melena:
Perform colonoscopy (if not performed
as the first-line intervention); consider
evaluation for small bowel bleeding
 Hemodynamically unstable patients
with ongoing bleeding: Consider
angioembolization
Angioembolization – nagiinject ng pang-
block or emboli to stop the bleeding sa
vessels.
- Consider intubation prior to endoscopy if
there is a high risk of aspiration
o It is important to subject the patient in an
endotracheal intubation to create
tamponade and prevent regurgitation and
aspiration since ET tube balloon will be
inflated.
 Colonoscopy (assess the lower GI tract)
o Source of GI bleeding identified:
Attempt endoscopic hemostasis.
 Through an endoscope mag-create ng
stasis para mahinto yung bleeding.
o Negative (nondiagnostic) colonoscopy
 Hemodynamically stable patients:
Evaluate for small bowel bleeding
 Hemodynamically unstable patients
with ongoing bleeding: Consult
surgery or angioembolization
- Lower endoscopy without bowel preparation
(including sigmoidoscopy) is not
recommended in the workup of acute LGIB.
VIDEO CAPSULE ENDOSCOPY (VCE)
 A diagnostic procedure using a tiny wireless
camera fitted inside a capsule that is swallowed
by the patient to take pictures of the mucosa in
the GI tract
 Pictures are analyzed after the capsule is
excreted 24-48 hours later.
- VCE is preferred in hemodynamically stable
patients with negative EGD and colonoscopy.
Hemodynamically unstable patients with
suspected small bowel bleeding should
undergo angiography.
IMAGING TESTS – may detect etiology of bleeding
 Angiogram – to help visualize abnormalities blood
vessels supplying the GI tract
 Computed Tomography Angiography (CTA)
o A diagnostic imaging technique that uses
computerized tomography, intravenous
administration of a radiocontrast agent
and specific timing to visualize blood
vessels of interest
o Also used to localize the source of GI
bleed
o Can detect bleeds as slow as 0.3-
0.5mL/minute
 After ma-inject and contrast
medium, magkakaroon ng series
of images para makita ang status
ng blood vessels.
  Abdominal CT Scan – help detect gastric or
duodenal ulcers or lesions that may cause or
predisposes the client to develop GI bleeding
MEDICAL-SURGICAL MANAGEMENT FOR PATIENTS
WITH GI BLEEDING
Management of GI Bleeding is based on etiology:
 If aspirin or NSAIDs are the cause 
discontinue medication and treat bleeding
 If ulcer is the cause  medication, dietary and
lifestyle modifications
 Therapeutic endoscopic procedure (cautery,
injection)
o Yung blood vessel na nagkakaroon ng
oozing of blood, that is the one being
cauterized or injected ng schelorsal agent
 Surgery may be indicated for cancers,
inflammatory diseases and vascular disorder
The following recommendations are consistent with the
2019 International Consensus Group (ICG) Nonvariceal
UGIB guidelines, the 2016 American College of
Gastroenterology (ACG) LGIB guidelines, the 2014
American Society for Gastrointestinal Endoscopy (AGSE)
LGIB guidelines
ALL PATIENTS
 Ensure patient is NPO
 Early identification of signs and symptoms of
Hypovolemic Shock and monitor vital signs every
15 to 30 minutes
o We need to assess the history but
address first the physiological needs of
patient for us to know if may signs
indicating hypovolemic shock
 Insert two large-bore (a 16- or 18-gauge needle)
peripheral IV lines for:
o Fluid resuscitation (Isotonic) – e.g.,
Lactated Ringers, and
 Isotonic to lessen the chances of
fluid shifting
 Plain LR – para mayroong fluid &
electrolytes
o Blood Transfusion (fresh whole blood,
packed RBC, and fresh frozen plasma)
 Obtain blood samples for laboratory studies (e.g.,
CBC, ABO typing and screening)
 Administer supplemental 02 delivered by
facemask or nasal cannula
 Insert an indwelling catheter – monitor UO hourly
o Urine output is an important indicator of
fluid volume status of patient
o Oliguria suggests that there is a
decreased perfusion
 Central Venous Pressure (CVP) may need to be
inserted
o Also called Right Atrial Pressure usually
measures 0-8mmHg
o Blood is received by the IVC/SVC and it
will be drained at the right atrium. The
CVP catheter ay iniisert sa may arms and
ithe-thread sa veins. Ang tip ng catheter
ay nasa junction ng SVC ang RA para
ma-measure ang fluid.
o Kung ang patient ay magma-manifest ng
8mmHg and above, it represents that
he/she is experiencing overhydration or
fluid overload.
o CVP/RAP represents the hydration status
of the patient. If 0 or negative ang CVP
measurement, it is an indication na
hypovolemic or decreased venous return.
 Conduct a focused history and examination
(including DRE)
 Risk stratify to guide further management
 Prior to endoscopic hemostatic procedures: (see
“Empiric Pharmacotherapeutic Interventions for GI
bleeding” for details) (PPI, Antibiotic,
Vasopressin, Analogs)
 Administer pre-treatment (e.g., IV PPI) as needed
 Administer anticoagulant reversal if INR > 2.5
o Antidote for Heparin: Protamine Sulfate
o Antidote for Warfarin: Vitamin K
o Sa mga patient na may bleeding and
nagtake previously ng warfarin and
heparin, kailangan ng antidote para
bumalik sa normal functioning ang blood
clotting mechanism since na-alter noong
may anticoagulant therapy.
o Kailangan i-reverse kasi patients are high
risk of massive bleeding.
 Consider withholding antithrombotic agents
NURSING MANAGEMENT
NURSING ASSESSMENT
o Assessment for a description of pain
o Assessment of relief measures to relieve the pain.
o Assessment of the characteristics of the vomitus.
o Assessment of the patient’s usual food intake and
food habits
NURSING DIAGNOSIS
o Acute pain related to the effect of gastric acid
secretion on damaged tissue.
o Anxiety related to an acute illness.
o Imbalanced nutrition related to changes in the diet.
o Deficient knowledge about prevention of symptoms
and management of condition
NURSING CARE PLANNING & GOALS
o The goals for the patient may include:
o Relief of pain
o Reduced anxiety
o Maintenance of nutritional requirements
o Knowledge about the management and
prevention of ulcer recurrence
o Absence of complications
NURSING INTERVENTIONS
o Nursing interventions for the patient may include:
o Relieving Pain and Improving Nutrition
 Administer prescribed medications.
 Medications to relieve the pain as well as
to manage the cause of ulcer formation
 Avoid aspirin, which is an anticoagulant,
and foods and beverages that contain
acid-enhancing caffeine (colas, tea,
coffee, chocolate), along with
decaffeinated coffee.
 Encourage patient to eat regularly
spaced meals in a relaxed atmosphere.
 Obtain regular weights and
encourage dietary modifications.
 Encourage relaxation techniques.
o Reducing Anxiety
 Assess what patient wants to know about
the disease and evaluate level of anxiety;
encourage patient to express fears
openly without criticism.
 Explain diagnostic tests and
administering medications on schedule.
 If PPI, or trying to eradicate the H. Pylori
or antacids which should be take at least
30 mins before meals
 To reduce anxiety and explain in a level
that they understand.
 Interact in a relaxing manner, help in
identifying stressors, and explain
effective coping techniques and
relaxation methods.
 Encourage family to participate in care
and give emotional support.
o Monitoring and Managing Complications: If
hemorrhage is a concern:
 Assess for faintness or dizziness and
nausea, before or with bleeding; test
stool for occult or gross blood; monitor
vital signs frequently (tachycardia,
hypotension, and tachypnea).
 Insert an indwelling urinary catheter and
monitor intake and output; insert and
maintain an IV line for infusing fluid and
blood.
 Replenish fluid losses, urine will signify
the concentration and fluid status.
 Monitor laboratory values (hemoglobin
and hematocrit).
 Insert and maintain a nasogastric tube
and monitor drainage; provide lavage as
ordered.
 Kailangan right pathway kung saan
lalabas ang drainage since post-op.
 Lavage = washing; intake=output,
aspirate by gravity.
 The only way to stop lavage if ordered
by a doctor, kapag yung output is clear,
no blood tinge or coffee ground.
 Monitor oxygen saturation and
administering oxygen therapy.
 Place the patient in the recumbent
position with the legs elevated to prevent
hypotension or place the patient on the
left side to prevent aspiration from
vomiting.
 Treat hypovolemic shock as indicated.
o Monitoring and Managing Complications: If
penetration are concerns.
 Note and report symptoms of penetration
(back and epigastric pain not relieved by
medications that were effective in the
past).
 Penetration= nag through and through to
another organ and system. Ex: pancreas
 Note and report symptoms of perforation
(sudden abdominal pain, referred pain to
shoulders, vomiting and collapse,
extremely tender and rigid abdomen,
hypotension and tachycardia, or other
signs of shock).
 Perforation is napunit. Example may
gastric cancer so napunit tumagos yung
laman sa peritonium and surrounding
areas
MANAGEMENT FOR PATEINTS WITH GI BLEEDING
 Nasogastric lavage
o Its use before endoscopy in the ER remains
controversial.
o Lavage is stomach wash
 Benefits:
 o To confirm an UGI source of bleeding (can  Lower Gi tract, nireremove
still miss up to 15%) yung polyps na possible
o Prognostic index for identifying high-risk nagcacause ng bleeding,
lesions as presence of fresh red blood in the
NGT aspirate.  Interventional Radiology (Angiography)
o Presence of blood will confirm na  Acute bleeding tapos di possible yung
may bleeding. endoscopic procedure kasi unstable yung
o May exclude false hematemesis. patient.
o Respiratory tract sputum -> linunok o Indications:
yung dugo  Preferred therapy in patients with
o To facilitate lavage of the upper GI tract to ongoing GI bleeding and
improve mucosal views at subsequent hemodynamic instability refractory to
endoscopy. resuscitation.
o If cause of bleeding is esophageal  An alternative to colonoscopy in
varices, insertion of NGT may patients with acute LGIB who cannot
traumatizes and increase bleeding tolerate bowel preparation.
tendencies.  Consider in patients with rebleeding or
o Reason to stop: if the return flow is ongoing bleeding despite endoscopic
clear. hemostasis.
o Techniques:
 Approach to Overt GI bleeding
o Emergency resuscitation  Angioembolization
 A minimally invasive
o Choice of source control modality depends
procedure used to selectively
on multiple factors (e.g., suspected
occlude the arterial supply of
hemorrhage source, hemodynamic status,
target tissue.
available resources)
 Primarily used to achieve
 Endoscopy is indicated, feasible, and
hemostasis non-operatively
able to identify the source of
but can also be used as an
bleeding: Attempt endoscopic
adjunct to surgical
hemostasis.
hemostasis.
 Endoscopy not recommended or
 Pinasok na pang
unable to identify the source of
emboli is a coil or gel
bleeding: angioembolization of
foam para mag stop
surgery.
yung bleeding.
o Identify and treat the underlying cause.
 Intraarterial vasopressin
 Approach to Occult GI bleeding  Vasopressin (Arginine
o Identify and treat underlying cause; correct vasopressin) (medication): a
anemia. synthetic ADH analog
 Used to treat vasodilatory
 Endoscopic Hemostasis shock, esophageal variceal
o Indications: any high-risk endoscopic findings hemorrhage, and control
 Signs of active bleeding diabetes insipidus.
 Nonbleeding visible vessel  Directly inject ng
 Adherent clot embolization particles
o Modalities  May cause emboli to
 Injection therapy (e.g., with diluted other area na
epinephrine, normal saline) madedeliver.
 Cauterization (e.g., heater probes,  Suspected LGIB
electrocauterization) o Stable patients: Refer for colonoscopy
 Sinusunog yung blood vessels o Perform EGD: done first for unstable patients
na nag open-up/ oozing blood with hematochezia and to any of the following:
 Mechanical therapy (e.g., band  High probability of UGIB
ligation, clips)  Moderate probability of UGIB with
 Polypectomy in the case of bleeding positive or inconclusive NG aspirate
polyp (e.g., in the colon)
 o Consider colonoscopy: first for unstable
patients with hematochezia and to all of the
following:
 Moderate probability of UGIB and
negative NG aspirate
 Able to tolerate rapid bowel prep.
o Consider angiography: for patients with
refractory hemodynamic instability.
o Consider surgery: if other options have failed
LOWER GI BLEED TREATMENT
 Management of Lower GIB is focused on colonoscopy
and mechanically treating bleeds with little
pharmacological intervention
o Look for the source & location of bleeding
o Wala masyadong tulong ang pharmacological
interventions when it comes to lower GI bleeding
 After the initial assessment and risk stratification, and
once the patient is hemodynamically stable:
o Colonoscopy preceded by colon cleansing is the
initial diagnostic procedure for most patient
presenting with a LGIB
 Management of LGIB mostly includes non-
pharmacologic interventions
 PPI Application in LGIB
o Evidence suggests that patients with LGIB do not
benefit from PPI therapy
NURSING ASSESSMENT
o Change in bowel patterns or hemorrhoids
o Change in color of stools
o Dark black
o Red
o Streaked with blood
o Alcohol consumption
o Medications such as:
o NSAIDs
o Antibiotics
o Anti-coagulants
o Corticosteroids
o Hematemesis
o Other medical conditions
o Examples: Liver cirrhosis, Cancer, etc.
o Evaluate for presence of abdominal pain
tenderness
o Monitor VS
o Monitor laboratory tests that indicated bleeding:
o Hemoglobin
o Hematocrit
o Platelet count
o Coagulation studies
o Test for occult blood if indicated
NURSING DIAGNOSES
o Deficient Fluid Volume related to blood loss
o Imbalanced Nutrition: Less Than Body Requirements
related to nausea, vomiting and diarrhea
NURSING INTERVENTIONS (ACTIVE BLEEDING)
o Monitor VS closely
o During the active bleeding, every 15-30 minutes
o Assess for signs of:
o Dehydration
 Fluid losses
o Hypovolemic shock
 Blood loss
o Sepsis
o Respiratory insufficiency
 Once hypovolemic shock occurs, the fluid
volume is decreased; the lungs would try to
compensate which results to rapid breathing
o Maintain NPO status and administer IV fluid
replacements as prescribed
o Lactated ringers, Plain LR (isotonic solution)
o To minimize chances of fluid shifting
o Insert another line for possible blood transfusion
o Monitor intake & output
o Foley catheter needs to be inserted
o Urine output reflects the fluid volume status of
the patient
o Monitor the urine output per hour
o Monitor hemoglobin and hematocrit
o Continuous bleeding = hemoglobin and
hematocrit will decrease in value
o Administer blood transfusions as prescribed
o Determine if the patient needs fresh raw blood,
RBC, platelet concentrate, or fresh frozen
plasma
o Prepare to assist with administering medications as
prescribed to induce vasoconstriction and reduce
bleeding
o Examples: Epinephrine, Vasopressin
o Attaining Normal Fluid Volume
o Maintain NG tube and NPO status
 NGT will be inserted and connected to a
drainage bottle, to allow for gastric
decompression; to drain secretion
or
 To allow the GI tract to rest
 To evaluate bleeding
o Monitor intake & output as ordered
 To evaluate fluid status
 Determining the patient’s output allows you
to know how much to replenish in terms of
 fluids & electrolytes since the patient is at
risk for dehydration and electrolyte
imbalances
 Volume per volume replacement; Lactated
Ringer solution
o Monitor VS as ordered
 Every 15 to 30 minutes
o Observe for changes indicating shock, such as:
 Tachycardia
 Hypotension
 Increased respirations
 Decreased urine output
 Change in mental status
o Administer IV fluids and blood products as
ordered to maintain volume
o Attaining Balanced Nutritional Status
o Weigh daily to monitor caloric status
o Administer IV fluids, TPN if ordered
 Promotes hydration and nutrition while on
oral restrictions
 Examples for TPN: Ready for use glucose,
amino acids, fatty acids, etc. that our body
needs to replace enteral feeding
 Usually makes use of the central line
because if you utilize the peripheral line,
there’s a possibility of phlebitis because the
TPN solutions used are highly osmolar &
hypertonic.
 IV fluids – crystalloids only
 TPN – can really provide nutrition, but are
pricey for the patient
o Begin liquids when patient is no long NPO
o Advance diet as tolerated
 Should be high-calorie, high-protein
 Frequent, small feedings may be indicated
 Offer snacks, high-protein supplements
o Patient Education and Health Maintenance
 Discuss the cause and treatment of GI
bleeding with patient
 Instruct patient regarding signs and
symptoms of GI bleeding
 Melena
 Emesis – bright red, or coffee grounds
in color
 Rectal bleeding
 Weakness
 Fatigue
 Shortness of breath
 Instruct patient on how to test stool or
emesis for occult blood, if applicable