Introduction


GASTROINTESTINAL
BLEEDING
Dr. Haitham Al-Amir
Lecturer of Internal Medicine
 Introduction
 Gastrointestinal bleeding (GIB) common clinical
problem

 GIB traditionally divided into either upper, lower

Or acute and chronic

Upper gastrointestinal bleeding (UGIB):

 bleeding from any source proximal to ligament of
Treitz
Lower gastrointestinal bleeding (LGIB):
 bleeding from any source distal to ligament of Treitz
 Epidemiology

 UGIB is more common than LGIB;

 UGIB approx. 67/100,000 population

 LGIB approx. 36/100,000 population

 LGIB:
 More common with increasing age
 More common in men

 mortality rate 2 - 4%
 GIB- Presentation
 Haematemesis: Vomiting of blood whether fresh
and red or digested and black.
 Melaena: Passage of loose, black tarry stools with
a characteristic foul smell.
 Coffee ground vomiting: Blood clot in the
vomitus.
 Hematochezia: Passage of bright red blood per
rectum, usually indicates bleeding from the
lower GI tract, but can occasionally be the
presentation for a briskly bleeding upper GI
source
 GIB- Presentation
 The presence of frank bloody emesis suggests more
active and severe bleeding in comparison to coffee-
ground emesis.
 Lower GI bleeding classically presents with
hematochezia, however bleeding from the right
colon or the small intestine can present with melena.
 Bleeding from the left side of the colon tends to
present bright red in color, whereas bleeding from
the right side of the colon often appears dark or
maroon-colored and may be mixed with stool.
 GIB- Presentation
 Other presentations which can accompany
GIB include hemodynamic instability,
abdominal pain and symptoms of anemia
such as lethargy, fatigue, syncope and angina.
 Patients with acute bleeding usually have
normocytic red blood cells. Microcytic red
blood cells or iron deficiency anemia suggests
chronic bleeding.
 Differential Diagnosis

 Occasionally, hemoptysis may be

confused for hematemesis or vice versa.
 Ingestion of bismuth containing products
or iron supplements may cause stools to
appear melanic.
Certain foods/dyes may turn emesis or stool
red, purple, or maroon (such as beets).
 UGIB
 Majority of patients with UGIB will spontaneously
cease.

 70-80% will stop within first 48 hrs of onset; of those

10-20% will have recurrence of UGIB. At initial
presentation ~20% will continue to bleed.

 Mortality greatest in these patients and also patients

that have recurrent bleeding
 Introduction
Etiology- UGIB

 Can divide causes into; variceal and non-

variceal
 Despite advances in diagnosis and treatment,
mortality of UGIB remains from 5 – 14%
 Mortality higher in patients > 60 yrs old and in
patients with multiple comorbid conditions
 % Etiology
50 Peptic ulcer disease
10 Esophageal varices
5-10 Mallory-Weiss tear
8-10 Esophagitis
2-5 Neoplasm
2-5 Angiodysplasia
10 Miscellaneous
 Miscellaneous
 Dieulafoy’s lesion (bleeding dilated vessel that erodes
through the gastrointestinal epithelium but has no primary
ulceration; can any location along the GI tract).
 Gastric Antral Vascular Ectasia (GAVE; also known as
watermelon stomach).
 Cameron lesions (bleeding ulcers occurring at the site of a
hiatal hernia).
 Post-surgical bleeds (post-anastomotic bleeding, post-
polypectomy bleeding, post-sphincterotomy bleeding).
 Hemobilia (bleeding from the biliary tract).
 UGIB

 20-30% of patients will have two or more

diagnoses of UGIB.
 No disease is found in 10-15% of patients
(prognosis is excellent).
 bleeding peptic ulcer disease most common
etiology and is also the most widely studied
 LGIB
 Diverticulosis (colonic wall protrusion at the site of
penetrating vessels; over time mucosa overlying the vessel can
be injured and rupture leading to bleeding).
 Angiodysplasia
 Infectious Colitis
 Ischemic Colitis
 Inflammatory Bowel Disease
 Colon cancer
 LGIB
 Hemorrhoids
 Anal fissures
 Rectal varices
 Dieulafoy’s lesion
 Radiation colitis
 Post-surgical (post-poly pectomy bleeding,
post-biopsy bleeding)
 UGIB- Initial Evaluation

Monitor hemodynamic status; Look for signs of

hemodynamic instability:
Resting tachycardia: associated with the loss of less than 15%
total blood volume
Orthostatic Hypotension: carries an association with the loss of
approximately 15% total blood volume
Supine Hypotension: associated with the loss of approximately
40% total blood volume
UGIB- Initial Evaluation

Confirm UGI source of bleeding by

 history (hematemesis – fresh blood or coffee
ground emesis, melena)
 Nasogastric aspiration is 80% sensitive for
actively bleeding UGI source
 False negative aspirates occur when the tube
is improperly positioned or when reflux of
blood from a duodenal source prevented by
pylorospasm or obstruction
UGIB- Lab Evaluation

 Complete blood count

Hemoglobin/Hematocrit

INR, PT, PTT

Liver and renal function tests

 UGIB- Treatment / Management
Risk Stratification
Specific risk calculators attempt to help identify
patients who would benefit from ICU level of care; most
stratify based on mortality risk.
The Rockall Score calculate the mortality rate of upper
GI bleeds. There are two separate Rockall scores; One is
calculated before endoscopy and identifies pre-
endoscopy mortality, whereas the second score is
calculated post-endoscopy and calculates overall
mortality and re-bleeding risks.
 UGIB- Treatment / Management

 Acute management of UGIB typically involves;

1. Assessment of the appropriate setting
2. Resuscitation
3. Supportive therapy
4. Investigating the underlying cause and attempting
to correct it.
 UGIB- Treatment / Management
Setting
ICU; Patients with hemodynamic instability,
continuous bleeding, or those with a significant risk of
morbidity/mortality should undergo monitoring in an
intensive care unit to facilitate more frequent
observation of vital signs and more emergent
therapeutic intervention.
 UGIB- Treatment / Management
Setting
Most patients with GI bleeding will require
hospitalization. However, some young, healthy
patients with self-limited and asymptomatic
bleeding may be safely discharged and evaluated
on an outpatient basis.
 UGIB- Resuscitation
 Nothing by mouth
 Adequate IV access - at least two large-bore
peripheral IVs or a centrally placed.
 Provide supplemental oxygen if patient
hypoxic (typically via nasal cannula, but
patients with ongoing hematemesis or altered
mental status may require intubation).
 UGIB- Resuscitation
 IV fluid resuscitation (with Normal Saline or
Lactated Ringer’s solution)
 Type and Cross matching.
 Transfusions:
RBC transfusion; typically started if hemoglobin is
< 7g/dL, including cardiac patients.
Platelet transfusion; started if platelet count <
50,000.
Prothrombin complex concentrate; if INR > 2
 UGIB- Resuscitation
Medications;
PPIs: Bolus (80 mg), followed by maintainence (8
mg/kg/hr)- 3-5 days-significant benefit in
decreasing recurrent bleeding.
Vasoactive medications: Somatostatin and its
analog octreotide can be used to treat variceal
bleeding by inhibiting vasodilatory hormone
release.
Erythromycin: Given to improve visualization at
the time of endoscopy.
 UGIB- Resuscitation
 Antibiotics; Considered prophylactically in
patients with cirrhosis to prevent SBP,
especially from endoscopy
 Anticoagulant/antiplatelet agents; Should be
stopped if possible in acute bleeds. Consider the
reversal of agents on a case-by-case basis
dependent on the severity of bleeding and risks
of reversal.
 UGIB- Resuscitation
 Placement of a sengestaken tube should be
considered in patients with hemodynamic
instability/massive GI bleeds in the setting of
known varices, which should be done only
once the airway is secured.
 This procedure carries a significant
complication risk (including arrhythmias,
gastric or esophageal perforation) and should
only be done by an experienced provider as a
temporizing measure.
 UGIB- Endoscopy
 Can be diagnostic and therapeutic. It is the test
of choice for identifying and treating the
bleeding lesion
 Allows visualization of the upper GI tract
(typically including from the oral cavity up to
the duodenum) and treatment with injection
therapy, thermal coagulation, hemostatic
clips/bands or band ligation.
 No role for barium studies in acute UGIB
 UGIB- Endoscopy

 Greatest benefit in the ~20% of patients with

continued or recurrent bleeding
 Improve morbidity and mortality: mortality
decreased by nearly 30%.
 Active bleeding can be controlled in 85-90% of
patients, with less than 3% complication rate.
 Should be done within 12-24 hrs.
 UGIB- Endoscopy
 Endoscopic Management
 Several endoscopic therapeutic techniques available to
attempt hemostasis in patients with UGIB
 Thermal
 Multipolar electrocautery /bipolar electrocautery
 Argon plasma coagulation
 Injection
 Epinephrine
 Mechanical
 Band Ligation
 Hemoclips (Endoclip)
 Endoscopy- Thermal

Small ulcer with a Site after eradication of

prominent visible the vessel using heater
vessel probe
Endoscopy- Haemoclips
Endoscopy- Band ligation
ALGORITHM TO UGIB