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1. Approach to GI
Hemorrhage
PRESENTED BY
ADISH JAIN
ADITIJ DHAMIJA

2.  Clinical presentation
 Resuscitation
 History and physicsl examination
 Labs and diagnostic tests
 UGI BLEED
 Causes and description
 LGI BLEED
 Causes and description
CONTENTS

3. Clinical Presentation of GI bleeding
• Occult bleeeding
• Vomiting of fresh or old blood
• Proximal to Treitz ligament
• Bright red blood = significant
bleeding
• Coffee ground emesis = no active
bleeding
• Passage of black & foul-smelling stools
• Usually upper source - may be right colon
• Passage of bright red blood from rectum If
brisk & significant > UGI source
• Bleeding not apparent to patient
May lead to dyspnea, AP & even MI
• Hematemesis
• Melena
• Hematochezia

4. Bleeding severity Vital Signs Blood loss (%)
Minor Normal < 10 %
Moderate Postural
(Orthostatic hypotension)
10 - 20 %
Massive Shock 20 - 25 %
(Resting hypotension)
Assessing the severity of bleeding
First step

5. Resuscitation
Proportional to bleeding severity
• 2 large-bore IV catheters: Normal saline - Ringer lactate
• Oxygen by nasal cannula or facemask
• Monitoring of vital signs & urine output
• Blood Transfusion:Ht raised to Elderly: 30 %
Young: 20- 25 %
PHT: 27-28 %
• Fresh frozen plasma & platelet transfusion
If transfusion of > 10 units of packed red blood cells

6. Symptoms of UGI bleeding
 Melenic or melenic stools- black tarry and foul smelling stools or dark
coloured stools
 Hematemesis
 Red hematemesis- vomiting of fresh blood
 Coffee ground hematemsis-vomiting of blood altered by stomach acids and
enzymes
 Dyspepsia
 Heartburn or Epigastric pain
 Abdominal pain
 Dysphagia
 Jaundice
 Weight loss
 Syncope
 Pallor

7. Symptoms of LGI Bleed
• Hematochezia-fresh blood in stools may be due to hemorrhoids or
anal fissures
• Bloody diarrhoea is typical of colitis, inflammation of colon
• Febrile episodes
• Hypovolemic shock or dehydration
• Abdominal cramps or pain
• Hypotension
• Pallor

8. • Elderly
• Young
• < 30 years
Diverticula - Angiodysplasia - Cancer
Peptic ulcer - Varices - Esophagitis
Meckel diverticula
Bleeding from similar causes
Aortoenteric fistula
• Previous bleeding
• Aortic surgery
• Known liver disease Esophageal or gastric varices
• NSAIDs
• Retching
• Non GI sources
Mallory-Weiss tear
Especially from nasopharynx

9. History
• Duration and quantity of bleeding
• Associated symptoms
• Previous history of bleeding
• Current medications
• Alcohol
• NSAID ASA use
• Allergies
• Associated medical illness
• Previous surgeries

10. History of bleed
• Hematemesis usually occurs with bleeding of esophafus, stomach and
proximal small bowel
• Melena will result from the presence of approximately 150-200ml of
blood in the GI tract for a prolonged period
• FALSE POSITIVE- Associated with the ingestion of certain fruits,
vegetables or red meat
• Hematochezia- or bloody stool, it’s often LGIB
• Could be due to a brick UGIB with rapid transit time through the
bowel.
• A more proximal source of significant bleeding must be excluded
before assuming the bleeding is from the lower GI tract

11. • PHT Spider naevi - caput medusa ...
• Acanthosis nigricans Underlying cancer
• Pigemnted lip lesions Peutz-Jeghers syndrome
• Cutaneous lesions
• Purpura
• Splenomegaly
• Telangiectasia
Neurofibromatosis
Henoch-Schonlein purpura
PHT - portal vein thrombosis
Osler-Weber-Rendu disease

18. • Congenital
• Cirrhosis:
Present in most patients
Due to hypoalbuminemia

20. Pigmentation of Axilla
Groins
Angles of mouth
Hands
Malignant disease Gastric carcinoma
Pancreatic carcinoma
Bronchial carcinoma

22. Nasal
afrway polyp
Breast
Neoplasia
Pancreatic
Carcinoma
lllucocutaneous
Pigmentation:
- Face
- Hands & feet
- Pe1ian.al
- Genit:alis
Testis
Sertoli cell hnnors
Ovary
Sex cord tumors
Bronchus
polyps
0 j,_o
Hamartomas
-l-+-:Ji:===7 Carcinomas:
- Stomach
- Smallintestine
- Colon
'H'----++-,'"- U1irulry tr.let
polyps

24. Age
Tetrad
Prognosis
Complications
Prepubertal boys (6 m - 6 years)
Can occurs in adults
Purpuric rash: feet - buttocks - legs
Colicky abdominal pain - bloody diarrhea
Arthralgia
Glomerulonephritis
Self-limited
Rapidly progressive renal failure
GI hemorrhage

27. • Hematocrit
• Elevated BUN
May not reflect blood loss accurately
Not correlated to creatinine level
Breakdown of blood proteins to urea
Mild reduction of GFR
• Iron deficiency anemia
• LowMCV
• Low ferritin level

28. • Test stools for occult blood, rectal examination
• Upper GI endoscopy
• Colonoscopy
• Small bowel endoscopy
• Capsule endoscopy & double balloon enteroscopy
• Barium radiograph
• Radionuclide imaging
• Angiography
• Miscellaneous tests: abdominal US or CT

29. The scores
• Rockall score- score less than 3 is good prognosis, more than 8
carries high risk of mortality
• Glasgow Blatchford Bleeding Score
• AIMS65 Score

30. TYPES of GI bleeding

31. Common Less Frequent Rare
Peptic ulcer Dieulafoy's lesion Esophageal ulcer
Varices Vascular ectasia Erosive duodenitis
Mallory-Weiss Watermelon stomach Hemobilia
Gastric varices Crohn 's disease
Neoplasia Aorto-enteric fistula
Esophagitis

32. • Most frequent cause of UGI bleeding (50%)
• Especially high on gastric lesser curvature
or postero-inferior wall of duodenal bulb
• Most ulcer bleeding is self-limited (80%)

33. Predisposing
factors to
bleeding PU
• Acid
• Helicobacter pylori
• NSAIDs
• Biphosphnate alendronate
• Chronic pulmonary disease
• Cirrhosis
• Anticoagulants
• Ethanol

34. Stage Characteristics Rebleeding
Ia Jet arterial bleeding 90%
lb Oozing 50 %
Ila Visible Vessel 25 - 30 %
Ilb Adherent clot 10- 20%
Ile Black spot in ulcer crater 7 - 10%
III Clean base ulcer 3- 5 %
Forrest's classification for PU bleeding

36. Treatmen
t of
bleeding
PU
• Pharmacological
• Endoscopic
• Surgical
PPI 80 mg IV bolus
8mg / hr / 72 hours IV infusion
Injection (epinephrine 1/10.000)
Monopolar coagulation
Bipolar coagulation
Heater probe
Hemoclips
Argon plasma coagulation
When endoscopic treatment fails

37. Summary of
therapy of
bleeding PU
• Patients must be adequately resuscitated
• UGI endoscopy is the primary diagnostic modality
• Intubation if severe bleeding or altered mental status
• Endoscopic therapy indicated in high risk lesions
Combine 2 methods of endoscopic treatment
• IV PPI should be used in high risk patients

39. New classification of esophageal varices
• Small Varices:
• Large Varices:
<5mm
>5mm

40. Gastro-Oesophageal Varices
Type I Along lesser curve
Type II To gastric fundus
Isolated Gastric Varices
Type I
Type II
Fundal
8% 2 "
Ectopic

41. Predictive factors for risk of bleeding
North Italian Endoscopic Club Index
• Variceal size
• Severity of liver disease
• Red signs
Best predictor of bleeding
Expressed by Child-Pugh
On the varices

42. Category 1 2 3
Bilirubin (mg/dl) <2 2-3 >3
Albumin (g/1) > 35 2 8 - 3 5 <28
Ascites Absent Mild- Moderate Severe
Encephalopathy 0 1-11 III- IV
INR < 1.7 1.7-2.3 > 2.3
(70%) (40- 70%) (< 40%)
Class A: 5-6 Class B: 7 - 9 Class C: 10 -15

43. 0.957 x Loge (creatinine mg/dL)
+
0.378 x Loge (bilirubin mg/dL)
+
1.120 x Loge (INR)
+
0.643*
Multiply score by 10 & round to nearest whole number
Laboratory values < 1.0 are set to 1.0
Maximum creatinine within MELD score: 4.0 mg/dl
Dialysis twice/week prior to creatinine test: creatinine 4.0 mg/dl
* 0.643 for etiology to make score comparable to previous published data

44. Treatment of acute variceal bleeding-1
• Best approach is combined use of:
- Pharmacological agent started from admission &
- Endoscopic procedure
• Terlipressin & somatostatin preferable if available
Octreotide, vasopressin + nitroglycerin may be used
• Drug therapy maintained for at least 48 h
5 day therapy recommended to prevent early rebleeding

45. Treatment of acute variceal bleeding-2
• Bleeding EV
Band ligation is the endoscopic treatment of choice
Sclerotherapy may be used
• Bleeding GV
Obturation with cyanoacrylate
• TIPS
Rescue procedure if medical & endoscopic tt fails
Bleeding from GV may require earlier decision for TIPS

46. Treatment of acute variceal bleeding-3
• Shunt surgery
Mesocaval graft shunts or traditional portacaval shunts
may be an alternative to TIPS in Child A patients
• Blood transfusion
Done cautiously using packed red cells (Ht: 25 - 28 %)
Plasma expanders to maintain hemodynamic stability
• Prophylaxis of infection
Given to all patients (norfloxacin 400 mg /12 hours)

50. Causes of bleeding in PHT
• Esophageal varices
• Gastric varices
• Ectopic varices
• Portal hypertensive gastropathy

53. 5- 10 % of UGI bleeding
Typically in gastric mucosa
Stop spontaneously in 80-90%
Not bleeding: discharge promptly
Active bleeding: injection - banding

60. LOWER GASTROINTESTINAL BLEED

61. List of causes of LGI Bleed:
• Diverticular disease — diverticulosis, diverticulitis
• Colitis: Ischaemic, Radiation and Infectious(Pseudomembranous colitis, E. coli, Shigella,
Salmonella, Campylobacter jejuni)
• Hemorrhoids
• Neoplasm — such as colorectal cancer
• Angiodysplasia
• Post-polypectomy bleed
• Inflammatory bowel disease such as Crohn's disease or ulcerative colitis
• Rectal varices
• Coagulopathy — specifically a bleeding diathesis
• Anal fissures
• Rectal foreign bodies
• Mesenteric ischemia
• NSAIDs
• Entamoeba histolytica

62. Severe Acute
• Diverticular disease
• Angiodysplasia
• Ischaemia
• Meckel’s diverticulum
• Inflammatory bowel disease
Chronic Acute/Sub Acute
• Fissure
• Haemorrhoids
• Inflammatory bowel disease
• Carcinoma
• Large polyps
• Angiodysplasia
• Radiation enteritis
• Solitary rectal ulcer
Causes of Lower Gastrointestinal Bleed (based on
onset)

63. SYMPTOMS:
• Melena: refers to dark black, tarry feces (>100-mL blood required for
one melenic stool) usually indicates bleeding proximal to ligament of
Treitz but may be as distal as ascending colon.
• Hematochezia: passage of bright red or maroon rectal
bleeding( indicating fresh blood) through the anus path, usually in or
with stools
• Symptoms of blood loss: e.g., light-headedness or shortness of
breath.
• Other associated symptoms
include: hypotension, tachycardia, angina, syncope, weakness, confusi
on, shock

64. Things to note in history and examination:
• History should include whether the bleeding is recurrent or sporadic
• Associated symptoms
• Detailed review of the patient's medications including, antiplatelets, anticoagulants, and NSAIDs
and past surgical history.
•The family history of colon cancer or inflammatory bowel disease (IBD) should also be noted.
•The presence of abdominal pain, especially if severe and associated with rebound tenderness or
involuntary guarding, raises concern for perforation. If any signs of an acute abdomen are present,
further evaluation to exclude a perforation is required prior to endoscopy.
• Digital rectal examination (DRE) inspect for hematochezia and anorectal pathology, such as
hemorrhoids.

65. Investigations:
• Complete blood count (CBC)
• Electrolyte evaluation
• Liver function tests
• Lactate levels
• Coagulation studies if the patient is on medications that would cause
them to be coagulopathic
• Lab work can revealpatients with microcytic hypochromic anemia due
to chronic blood loss

66. Algorithm for management:
The follow flowchart provides a template for care for a patient present with a lower GI bleed

67. Severe acute lower gastrointestinal bleeding
• This presents with profuse red or maroon diarrhoea and with hypovolaemic shock.
• If available, CT angiography should be performed initially to localise the site of blood
loss.
• If the bleeding source is identified, then catheter angiography with embolisation should
be performed.
• If no source of bleeding is found then a colonoscopy should be performed.
• Some patients presenting with an apparent severe lower GI bleed are ultimately found to
have a significant upper GI bleed.

68. Etiologies for severe acute bleeds:
Diverticular disease:
• Most common with up to two-thirds of cases being classified as severe.
• Bleeding from diverticular disease is often due to erosion of an artery within the mouth of a diverticulum.
• Multiple endoscopic options are available, with endoscopic clipping either alone or after the injection of
dilute adrenaline (epinephrine).
Angiodysplasia
• It's a disease of older adults, in which vascular malformations develop within the GI tract, commonly in the
caecum.
• Bleeding can be acute and profuse; it usually stops spontaneously, but commonly recurs.
• Colonoscopy may reveal characteristic vascular spots and, in the acute phase, angiography can show
bleeding into the intestinal lumen and an abnormal large, draining vein.
• The treatment of choice is endoscopic thermal ablation, but resection of the affected bowel may be
required if bleeding continues.

69. Bowel ischaemia
• Due to occlusion of the inferior mesenteric artery can present with abdominal colic and
rectal bleeding.
• It should be considered in patients (particularly older patients) who have
evidence of generalised atherosclerosis.
• Common areas are watershed areas of the colon: splenic flexure and rectosigmoid
junction
• The diagnosis is made at colonoscopy. Resection is required only in the presence of
peritonitis.
Meckel’s diverticulum
• A diverticulum with ectopic gastric epithelium may ulcerate and erode into a major
artery.
• The diagnosis should be considered in children or adolescents who present with profuse
or recurrent lower gastrointestinal bleeding.
• A Meckel’s 99m Tc-pertechnetate scan is sometimes positive, but the diagnosis
is commonly made only by laparotomy, at which time the diverticulum is excised.

70. Chronic lower gastrointestinal bleed:
• This can occur at all ages and is usually due to haemorrhoids or anal fissure.
• Haemorrhoidal bleeding is bright red and occurs during or after defecation. Proctoscopy
can be used to make the diagnosis, but individuals who have altered bowel habit and
those who present over the age of 40 years should undergo colonoscopy to exclude
coexisting colorectal cancer.
• Anal fissure should be suspected when fresh rectal bleeding and anal pain occur during
defecation.