Acute upper gastrointestinal bleeding Haematemesis : is
the vomiting of blood from a lesion proximal to the distal
Melaena is the passage of black tarry stools; the black
colour is due to blood altered by bacteria - 50 mL or more is
required to produce this.
Melaena can occur with bleeding from any lesion from
areas proximal to and including the caecum.
Following a massive bleed from the upper GI tract,
unaltered blood (owing to rapid transit) can appear per
rectum, but this is rare.
The colour of the blood appearing per rectum is dependent
not only on the site of bleeding but also on the time of
transit through the gut.
The causes for upper GI hemorrhage include the following:
Gastric antral vascular ectasia.
Hematobilia, or bleeding from the biliary tree
Hemosuccus pancreaticus, or bleeding from the pancreatic duct
Peptic ulceration is the commonest cause of serious
and life threatening gastrointestinal bleeding.
Drugs. Aspirin (even 75 mg a day) and other NSAIDs
can produce gastric lesions.
These agents are also responsible for GI haemorrhage
from both duodenal and gastric ulcers, particularly in
the elderly. Corticosteroids in the usual therapeutic
doses probably have no influence on GI haemorrhage.
Anticoagulants do not cause acute GI haemorrhage per
se but bleeding from any cause is greater if the patient
The following factors affect the management:
the amount of blood lost, which may give some guide to the
continuing visible blood loss
signs of chronic liver disease on examination
evidence of co-morbidity, e.g. cardiac failure, ischaemic heart
disease, renal disease and malignant disease
presence of the classical clinical features of shock (pallor, cold
nose, tachycardia and low blood pressure )
With liver disease, the bleeding is often severe and recurrent if it
is from varices. Splenomegaly suggests portal hypertension but
its absence does not rule out oesophageal varices.
With shock, remember that the peripheral arterial constriction
that occurs may keep the blood pressure falsely high.
Management of acute gastrointestinal bleeding
Rapid history and examination.
Monitor the pulse and blood pressure half-hourly.
Take blood for haemoglobin, urea, electrolytes, ,liver functions ,blood
grouping and crossmatching .
Establish intravenous access - central line if brisk bleed.
Give blood transfusion/colloid if necessary.
Stop drugs, e.g. NSAIDs, warfarin
Indications for blood transfusion are:
(a) SHOCK (pallor, cold nose, systolic PB below 100 mmHg, pulse > 100
(b) haemoglobin < 10 g/dL in patients with recent or active bleeding.
Oxygen therapy for shocked patients.
Urgent endoscopy in shocked patients/liver disease.
Continue to monitor pulse and BP.
Re-endoscope for continued bleeding/hypovolaemia.
Surgery if bleeding persists.
Urgent resuscitation is required in patients with large
bleeds and the clinical signs of shock.
Oxygen should be given by face mask and the patient
should be kept nil by mouth until endoscopy has been
The major principle is to rapidly restore the blood volume
to normal. This can be best achieved by transfusion of
whole blood via one or more large-bore intravenous
cannulae; physiological saline is given until the blood
becomes available .
The rate of blood transfusion must be monitored carefully
to avoid overtransfusion and consequent heart failure.
The pulse rate and venous pressure are the best guides to
should be performed within 24 hours in most patients.
Early endoscopy helps to make a diagnosis and to make
decisions regarding discharge from hospital, particularly in
patients with minor bleeds and under 60 years of age.
Urgent endoscopy (i.e. after resuscitation) should be
performed in patients with shock, suspected liver disease
or with continued bleeding.
Endoscopy can detect the cause of the haemorrhage in
80% or more of cases. In patients with a peptic ulcer, if the
stigmata of a recent bleed are seen (i.e. a spurting artery,
active oozing, fresh or organized blood clot or black spots)
the patient is more likely to re-bleed.
At first endoscopy: varices should be injected.
all bleeding ulcers should be either injected with epinephrine
(adrenaline), the vessel coagulated either with a heater probe or
with laser therapy or metallic clips applied.
These methods reduce the incidence of re-bleeding, although
they do not significantly improve mortality as re-bleeding still
occurs in 20% within 72 hours.
Intravenous omeprazole 80 mg followed by infusion 8 mg/h for
72 hours should be given to all patients in this group, as it
reduces re-bleeding rates and the need for surgery.
Drug therapy :There is little evidence that H2-receptor
antagonists or proton-pump inhibitors (PPIs) affect the mortality
rate of GI haemorrhage, but PPIs are usually given to all patients
with ulcers because of their longer-term benefits.
Somatostatin (which reduces the splanchnic blood flow as well
as acid secretion) can be given as an infusion if the bleeding is
difficult to stop.
Age is clearly significant. Below the age of 60 years
mortality from GI bleeding is small, < 0.1%, but above
the age of 80 the mortality is greater than 20%.
Patients with recurrent haemorrhage have an
Most re-bleeds (approximately 20% of all cases) occur
within 48 hours.
Co-morbidity invariably increases mortality.
Presence of shock at any time increases mortality.
Lower GIT bleeding
Acute lower gastrointestinal bleeding
Massive bleeding from the lower GI tract is rare.
On the other hand, small bleeds from haemorrhoids
occur very commonly.
Massive bleeding is usually due to diverticular disease
or ischaemic colitis.
The causes of lower gastrointestinal bleeding are
Coagulopathy - specifically a bleeding diathesis
E. coli .
Neoplasm - cancer
Diverticular disease - diverticulosis, diverticulitis
Most acute lower GI bleeds start spontaneously. The few patients
that continue bleeding and are haemodynamically unstable need
resuscitation using the same principles as for upper GI bleeding .
Surgery is rarely required.
A diagnosis is made using the history, and the following
investigations as appropriate: rectal examination (e.g.
proctoscopy (e.g. anorectal disease, particularly haemorrhoids)
sigmoidoscopy (e.g. inflammatory bowel disease)
barium enema - ischaemic colitis
colonoscopy - for any mucosal lesion and removal of polyps
angiography - vascular abnormality (e.g. angiodysplasia )
Isolated episodes of rectal bleeding in the young (< 45 years)
only require rectal examination and sigmoidoscopy. Colorectal
cancer is rare in this age group without a strong family history.
Individual lesions are treated as appropriate.
Chronic gastrointestinal bleeding
Patients with chronic bleeding usually present with
iron-deficiency anaemia .
Chronic blood loss producing iron deficiency anaemia
in all men and all women after the menopause is
always due to bleeding from the gastrointestinal tract,
often from a right-sided colonic neoplasm which must
be excluded. Occult blood tests are necessary .
Measurement of faecal occult blood
It is only of value in: premenopausal women - if a
history of menorrhagia is uncertain and the cause of
iron deficiency is unclear
mass population screening for large bowel malignancy.
Advantages: cheap and easy to perform.
Disadvantages: high false-positive rate, leading to
Chronic blood loss can occur with any lesion of the
gastrointestinal tract that produces acute bleeding .
It is, however, usual for oesophageal varices to bleed severely and
rarely to present as chronic blood loss.
It should be remembered that, world-wide, hookworm is the
most common cause of chronic gastrointestinal blood loss.
History and examination may indicate the most likely site of the
bleeding, but if no clue is available it is usual to investigate both
the upper and lower gastrointestinal tract endoscopically at the
same session ('top and tail').
For practical reasons an upper gastrointestinal endoscopy is
performed first as this takes only minutes, followed by
colonoscopy when any lesion can be removed or biopsied.
A barium enema is performed only if colonoscopy is unavailable.
A small bowel follow-through is the next investigation, but the
diagnostic yield is very low
Endoscopes to visualize the whole of the small bowel
(enteroscopy) are available at specialist centres.
Wireless capsule endoscopy is useful, particularly with
melaena of obscure origin (90% of causes were found
in a recent study).
Treatment :The cause of the bleeding should be
treated, if found. Oral iron is given to treat anaemia