Selmar Maribojo Jr, MD
First Year Medical Resident
Most common gastrointestinal condition
leading to hospitalization in the United States
Presents either Overt GI bleeding or Occult
GI bleeding
Site of bleeding:
UGIB (esophagus, stomach, duodenum)
LGIB (colonic)
Small intestinal or obscure GIB (if the source is
unclear).
Hematemesis
Vomitus of red blood or “coffee-grounds” material
Melena
Black, tarry stool
Blood has been present in the GI tract for ≥14 h,
and as long as 3–5 days.
Hematochezia
Passage of red or maroon blood from the rectum
Present with symptoms of blood loss or
anemia
Lightheadedness
Syncope
Angina
Dyspnea
Iron-deficiency anemia
Positive fecal occult blood test on routine testing
Heart rate and Blood pressure - best way to
initially assess a patient with GIB
Acute GIB
Hemoglobin does not fall immediately at initial
presentation
Chronic GIB
May have very low hemoglobin values despite
normal blood pressure and heart rate.
Hemoglobin does not fall immediately with
acute GIB
Hemoglobin does not fall immediately with
acute GIB
may be normal or only minimally decreased
Hemoglobin does not fall immediately with
acute GIB
may be normal or only minimally decreased
Extravascular fluid
GI bleeding enters the vascular
episodes space
Hemoglobin does not fall immediately with
acute GIB
may be normal or only minimally decreased
Extravascular fluid
GI bleeding enters the vascular
episodes space
72 hours
Hemoglobin does not fall immediately with
acute GIB
may be normal or only minimally decreased
Extravascular fluid
GI bleeding enters the vascular ↓Hgb falls
episodes space
72 hours
Hemoglobin does not fall immediately with
acute GIB
may be normal or only minimally decreased
Extravascular fluid
GI bleeding enters the vascular ↓Hgb falls
episodes space
Hemoglobin below
7g/d
Upper GIB source
Hematemesis
Hematochezia
▪ May bleed so briskly that blood transits the bowel
before melena develops.
▪ Associated with hemodynamic instability and dropping
hemoglobin
Hyperactive bowel sounds
Elevated blood urea nitrogen
Small bowel source
Melena or Hematochezia
Lower GIB source
Hematochezia
Upper GI Source of Small-Intestinal Colonic source of
Bleeding Sources of Bleeding Bleeding
Peptic Ulcer Disease Vascular ectasias Hemorrhoid
Mallory Weis Tears Neoplasm Anal fissure
Esophageal Varices NSAID-induced erosions Diverticulosis
and ulcers
Erosive Disease Meckel’s diverticulum Vascular ectasias
Neoplasm Crohn’s disease Neplasm
Vascular ectasias Polyposis syndromes Colitis
Dieulafoy lesion Dieulafoy’s lesions Postpolypectomy
Aortoenteric fistulas Aortoenteric fistulas Radiation proctopathy
Hemobilia Small-bowel varices Aortocolic fistulas
Hemosuccus pancreaticus Diverticula Rectal varices
Intusseption Inflammatory bowel
disease
Duplication cyst Juvenile polyps.
Peptic ulcer
Mallory weiss Tear
Esophageal varices
Erosive Disease
Less common:
Neoplasms
Vascular ectasias
Dieulafoy’s lesion
Prolapse gastropathy
Aortoenteric fistulas
Hemobilia
Hemosuccus pancreaticus
Most common cause of UGIB
~50% of UGIB hospitalizations.
Features of an ulcer at endoscopy provide
important prognostic information
High risk ulcer:
▪ Active bleeding, nonbleeding visible vessel, adherent
clot
Low risk ulcer:
▪ Flat pigmented spot or clean base
Indications:
Active bleeding, nonbleeding visible vessel or
adherent clot
Perform early
Reductions in bleeding, hospital stay,
mortality, and costs
Heater Probe, Bipolar electrocoagulation, Injection
therapy (e.g., absolute alcohol, 1:10,000
epinephrine), and/or clips
Flat pigmented spot/Clean-based ulcers
Have rates of serious recurrent bleeding
approaching zero.
Do not require endoscopic therapy and receive
standard doses of oral PPI.
If stable with no other reason for hospitalization,
may be discharged home after endoscopy
Treatment: High-dose, constant-infusion IV
proton pump inhibitor (80-mg bolus and 8-
mg/h infusion)
Sustain intragastric pH >6
Enhance clot stability
Decreases further bleeding and mortality in
patients with high-risk ulcers
High-dose intermittent PPIs are non-inferior
to constant-infusion PPI therapy
Active Flat
Endoscopic
bleeding Adherent clot pigmented Clean base
features visible vessel spot
Endoscopic
yes May consider no no
Therapy
Medical Intensive PPI Intensive PPI Once daily PPI Once daily PPI
Therapy Therapy Therapy Therapy therapy
Clear liquids x Clear liquids x Clear liquids x
Diet Regular diet
2 days 2 days 1 day
Hospital stay 3 days 3 days 1-2 days Discharge
•Vomiting Endoscopic Active No active
features bleeding bleeding
•Retching
•Coughing
Endoscopic
preceding Yes No
Therapy
hematemesis
•Alcoholic patient Medical Antiemetic if Antiemetic if
Therapy nausea nausea
Clear liquids x
Diet Regular
1 day
Hospital stay 1-2 days discharge
Poorer outcomes
Urgent endoscopy within 12 h is recommended in
cirrhotics with UGIB
Endoscopic ligation should be performed
Medical therapy:
IV vasoactive medication (octreotide, somatostatin,
vapreotide, terlipressin) is given for 2–5 days.
Nonselective beta blockers plus endoscopic
ligation
Showed reduction of recurrent esophageal variceal
bleeding.
Transjugular intrahepatic portosystemic
shunt (TIPS)
Recommended in patients who have persistent or
recurrent bleeding despite endoscopic and
medical therapy.
Considered in the first 1–2 days of hospitalization
for acute variceal bleeding in patients with
advanced liver disease
Endoscopic
Ligation
Therapy
Followed by
Medical Vasoactive Octreotide 50 50mcg
Therapy drug mcg IV bolus infusion for 2-
5 days
Clear liquids
Diet
for 2 days
Hospital stay 3-5 days
Visualized breaks which Endoscopic
No
Therapy
are confined to the
mucosa Medical Once daily
Therapy therapy
Causes:
NSAID use Diet Regular
Alcohol intake
H. pylori infection Hospital stay discharge
Stress-related mucosal
injury.
Stress-related mucosal injury
Occurs only in extremely sick patients,
▪ Serious trauma
▪ Major surgery
▪ Burns covering more than one-third of the body surface
▪ Major intracranial disease
▪ Severe medical illness
Mortality rate in these patients is high because of
their serious underlying illnesses.
Erythromycin 250mg IV
Promotility agent
Given ~30 min before endoscopy,
Improve visualization : provides a small but
significant increase in diagnostic yield and
decrease in red cell transfusions.
Quinolone or Ceftriaxone:
Should be given with Cirrhotic patients presenting
with UGIB
IV vasoactive medication
Improve control of bleeding in the first 12 h after
presentation
Upper endoscopy
Performed within 24 h in most patients with UGIB.
Patients at higher risk (e.g., hemodynamic
instability, cirrhosis) may benefit from more
urgent endoscopy within 12 h.
Early endoscopy is also beneficial in low-risk
patients for management decisions (e.g.,
discharge).
Obscure GIB
Patients without a source of GIB identified on
upper endoscopy and colonoscopy
75% of GIB previously labeled obscure
Estimated to originate in the small intestine
beyond the extent of a standard upper endoscopic
exam.
Small-intestinal GIB may account for up to
~5–10% of GIB cases.
Most common causes in adults >40 years
Vascular ectasias, neoplasm (e.g., GI stromal
tumor, carcinoid, adenocarcinoma, lymphoma,
metastases), and NSAID-induced erosions and
ulcers.
Causes in patients <40 years
Crohn’s disease, polyposis syndromes, or
neoplasm
Meckel’s diverticulum
Most common cause in children
Small-intestinal vascular ectasias are treated
with endoscopic therapy
Rebleeding is common:
45% over a mean follow-up of 26 months
Treatment:
Octreotide
Surgical resection
Hemorrhoids - most common cause of LGIB
Other causes:
Diverticulosis
Vascular ectasias
Neoplasms
Colitis
Postpolypectomy bleeding
Radiation proctopathy.
Rarer causes
Solitary rectal ulcer syndrome
Trauma
Varices (most commonly rectal)
Lymphoid nodular hyperplasia
Vasculitis
Aortocolic fistulas
In children and adolescents,
Inflammatory bowel disease
Juvenile polyps.
Diverticular bleeding
Abrupt in onset
Usually Painless
Sometimes massive
Often from the right colon
Chronic or occult bleeding is not characteristic.
Stop bleeding spontaneously in ~80–90%
Rebleed in ~15–40% of patients..
Endoscopic therapy
Decrease recurrent bleeding in the uncommon
case when colonoscopy identifies the specific
bleeding diverticulum
Transcatheter arterial embolization by
superselective technique
Stops bleeding in a majority of patients.
Segmental surgical resection
Recommended for persistent or refractory
diverticular bleeding
Patients with hematochezia and
hemodynamic instability should have
“upper endoscopy” to rule out an upper GI
source before evaluation of the lower GI tract.
Colonoscopy
After an oral lavage solution is the procedure of
choice in most patients admitted with LGIB
Bleeding is too massive Angiography
Computed tomography (CT) angiography
Suggested prior to angiography to document
evidence and location of active bleeding.
Sigmoidoscopy
Used primarily in patients <40 years old with
minor bleeding.
Imaging studies: 99m Tc-Labeled red cell scan
In patients with no source identified on
colonoscopy
allows repeated imaging for up to 24 h and may
identify the general location of bleeding.
Angiography
The initial test, with CT angiography or 99mTc-
labeled red cell scan prior to angiography if the
patient’s clinical status permits.
Repeat upper and lower endoscopy may be
considered as the initial evaluation because
second-look procedures identify a source in
up to ~25% of upper endoscopies and
colonoscopies
Video capsule endoscopy.
Showed the yield of “clinically significant
findings”.
Disadvantage:
▪ Does not allow full visualization of the small intestine
▪ Tissue sampling
▪ Application of therapy.
CT enterography
Used initially with possible small bowel narrowing
(e.g., stricture, prior surgery or radiation, Crohn’s
disease)
Given its higher sensitivity for small-intestinal
masses.
Deep” enteroscopy (double-balloon, single-
balloon, or spiral enteroscopy)
Commonly the next test undertaken for clinically
important GIB documented or suspected to be
from the small intestine
Allows to examine, obtain specimens from, and
provide therapy to much or all of the small
intestine.
No Hemodynamicaly
instability
Age < 40 years Site identified,
Bleeding stop
Minimal Copious
Bleeding bleeding, Site identified,
Angiography/
Fx of Colon CA, Bleeding
Surgery
IDA persist
Flexible
Sigmoidoscopy Work up for
small
Site not intestinal/
Colonoscopy
identified Obscure
bleeding site
No Hemodynamicaly
instability
Age ≥ 40 years Site identified,
Bleeding stop
Site identified,
Colonoscopy Angiography/
Bleeding
Surgery
persist
Work up for
small
Site not intestinal/
identified Obscure
bleeding site
Hemodynamicaly instability
Upper Site identified,
Endoscopy Bleeding stop
No Upper GI Site identified,
Angiography/
source Bleeding
Surgery
persist
Unable to prep Work up for
small
Site not intestinal/
Angiography Colonoscopy
identified Obscure
bleeding site
Hemodynamicaly instability
Upper
Endoscopy
Surgery (with
intraoperative
endoscopy if
No Upper GI site has not
source been
identified)
Unable to prep
Bleeding,
Angiography Instability
persist
Recommended only for colorectal cancer
screening
Age 50 in average-risk adults.
Positive test colonoscopy
Negative no further workup, unless iron-
deficiency anemia or GI symptoms are present.
Upper GI Source of Small-Intestinal Colonic source of
Bleeding Sources of Bleeding Bleeding
Peptic Ulcer Disease Vascular ectasias Hemorrhoid
Mallory Weis Tears Neoplasm Anal fissure
Esophageal Varices NSAID-induced erosions Diverticulosis
and ulcers
Erosive Disease Meckel’s diverticulum Vascular ectasias
Neoplasm Crohn’s disease Neplasm
Vascular ectasias Polyposis syndromes Colitis
Dieulafoy lesion Dieulafoy’s lesions Postpolypectomy
Aortoenteric fistulas Aortoenteric fistulas Radiation proctopathy
Hemobilia Small-bowel varices Aortocolic fistulas
Hemosuccus pancreaticus Diverticula Rectal varices
Intusseption Inflammatory bowel
disease
Duplication cyst Juvenile polyps.
