1. GI bleed
Upper GI- proximal to ligament of Treitz
&
Lower GI- distal to ligament of Treitz

2. Acute UGI bleeding
Causes hematemesis or malena
Hematochezia- rare

3. Etiology
 Peptic ulcer disease- commonest
 Varices- esophageal, rarely gastric
 Mallory-Weiss tear at GE junction
 Erosive gastritis- stress, alcohol,
NSAIDs
 Rare-
 Vascular ectasias
 Cancer
 Erosive esophagitis

4. Management- in ER
 A.B.C.
 Hypotension & tachycardia suggest
severity of bleed, not hematocrit
 Two large bore IV canulas for fluid &
blood replacement
 Check CBC, INR, Cr, SGPT, blood
group
 NG tube to confirm & quantitate bleed
 PRBC, FFP, PRP transfusion; as

5. Management- later
 H & PE suggesting possible cause- PUD, CLD, drugs
 UGIE- once patient stabilized, sooner the better,
helps-
 Identify source
 Determine risk of rebleed
 Render endoscopic therapy
 Drugs-
 PPI- IV or oral- for PUD
 Octreotide/Terlipressin- CIVI- for variceal bleed
 Other Rx-
 TIPS
 Intra-arterial embolization

6. Surgery
If all else fails

7. Acute LGI bleed
 Commonly from colon- ~85%,
only ~5% from small intestine
 Mild anorectal bleed to
frank hematochezia
 Mixed with stool?
 Less serious, more benign
 Spontaneously subsides in ~85%

8. Etiology
 Young-
 Infectious colitis
 Anorectal disease
 IBD
 Older-
 Diverticulosis- commonest cause of major LGI bleed
 Vascular ectasia
 Polyps or Malignancy
 Ischemia

9. Management- in ER
Hemodynamic assessment- PR & BP
Labs- CBC, INR, Cr, SGPT
IVF & blood products

10. Evaluation- later
 UGIE- to rule out UGI source of bleed
 Proctoscopy/sigmoidoscopy
 Localize proximal colonic bleed
 Colonoscopy
 Nuclear bleeding scan- 0.1 ml/min
 Selective angiography- 0.5 ml/min
 Push enteroscopy/capsule imaging-
to detect SI bleeding

11. Treatment
 Therapeutic colonoscopy-
 Epinephrine injection, cautery, clipping
 Intra-arterial vasopressin/embolization-
 For poor surgical candidates
 Surgery- significant blood loss- 4-6 units
over 24 hours or >10 units BT
 Localized lesion- limited resection
 Not localized lesion- extensive resection
 Recurrent bleeding

12. Occult GI bleed
 Not apparent to the patient
 Identified as +ve FOBT/FIT or
iron-deficiency anemia
 Causes-
 Malignancy, vascular ectasias, PUD, erosions
 Infection- hookworm, TB
 Drugs- aspirin, NSAIDs
 Ix- UGIE ± colonoscopy
 Rx- iron replacement ± transfusion while
evaluatingRx of cause detected, if any

13. Obscure GI bleed
 No source identified despite UGIE & colonoscopy
 Overt or Occult
 Evaluation- depends on age & symptoms;
aggressive in younger or symptomatic patients
 Ix-
 Repeat UGIE + colonoscopy
 Capsule endoscopy
 Angiography
 CT scan
 Laparotomy