This document outlines the management of gastrointestinal bleeding. It discusses primary, secondary and acute variceal bleeding management. For primary prophylaxis of variceal bleeding, propranolol or nadolol are recommended. For acute variceal bleeding, endoscopic interventions like band ligation or cyanoacrylate injection along with antibiotics and vasoconstrictors are used. Secondary prophylaxis involves medications like propranolol, nadolol or isosorbide to prevent rebleeding. It also discusses portal hypertensive gastropathy, acute lower gastrointestinal bleeding and provides an algorithm for management of acute LGIB.

1. Primary prophylaxis of bleeding eso varices:
Propranolol
FU OGD after
Obliteration:
3 MONTHLY
For 1 year
Then
Yearly
Indefintely.
Or
Nadolol
EBL
Sessions every
4 weeks
PP of EV
bleed
Propranolol 20mgm*2
untill PR 55/min
Indefinite
Nadolol 40mgm once daily
Untill PR 55/min
Indefinite
Endoscopic band ligation
Evey 4 weeks untill total obliteration
Follow up: 3 /12 for 1 year, yearly
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2. Management of acute variceal bleeding:
Endoscopic
Intervention
EBL
Sclerotherapy
Sigestaken
Tube temponade
Cyanoacrylate
Injection
Sclerotherapy
For gastric
Varices.
Antibiotics:
Ceftriaxone
Ciprofloxacin
5 days
Vasoconstrictor
Octreotite
Somatostatin
Telipresin
5 days
Esophageal
stenting
Acute variceal
Bleeding.
4

3. Secondary prophylaxis( prevention of
recurrent) of bleeding EV:
propranolo Nadolol
Cyanoacrylate
for GV
EBL for
EV
Interventional
Radiology for
GV
Isosorbide
Secondary prophylaxis
Propranolol
Same as for primary prophylaxis.
Nadolol
Same as for primary prophylaxis.
Isosorbide dinitrate
10 mgm*10-20 mgm*2
EBL
Same as for primary prophylaxis.
Cyanoacrylate injection
sclerotherapy or IR for gastric
varices not EBL.
5

4. Portal Hypertensive Gastropathy
•PHT- related ectatic gastric mucosal vessels mostly in fundus
& body of the stomach.
Definition:
GEV , Child class& prior variceal endoscopic therapy
Chronic blood loss leading to IDA rather than acute bleeding
Iron supplementation;BB,Shunt therapy(surgeryorTIPS)
Same.
Predictors of its presence
Prsentation
Treatment:
Prophylaxis
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5. Acute Lower Gastrointestinal Bleeding
Bleeding distal to the ligament of Treitz for <less than 3 days.
The colon is the most common site of bleeding.
The incidence increases with age, with mean of 63-77 years.
LGIB accounts for 20% of all episodes of GIB.
Most episodes of LGIB will stop without intervention.
The most common causes of acute LGIB are diverticulosis, angiectasia,
ischemic colitis, perianal disease.
The most frequent causes of chronic LGIB are neoplasms, angiectasia, IBD.

6. Causes in Our locality:
Perianal diseases(piles/Fissure)
IBD(UC>CD)
Infectious colitis
Neoplasms(adenoma or cancer)
Solitary rectal ulcer syndrome
(SRUS)
Meckel’s diverticulum.
Ischemic colitis.
Angiodysplasia

7. Hemorrhoids/ fissures:
Bleeding after/or with
defecation
Pain & bleeding with
defecation
Careful perianal exam+ anoscopy
assist in the diagnosis
Piles Fissure
1
2

8. Acute LGIB: Management algorythm
Initial evaluation/ resuscitation
Triage to OP vs Ward vs ICU
Mild scanty bleeding Anorectal pathology
susspected
Rigid Anoscopy or
sigmoidoscopy to
confirm diagnosis
Outpatient
management
Anorectal pathology(piles/fissure) is the most common pathology in our locality
But this should be diagnosed on solid basis not to miss serious pathologies as IBD or
cancer.

9. Severe bleeding
Severe exanguinating
bleeding
Emergency
angiography for
bleeding control by
gel form or coils
Or emergency surgical
consult.
If emergency angio
succeeded just
observe for
recurrence but if
fails refer to surgery
SURGERY
Severe exanguinating bleeding needs urgent action either emergency surgery or
emegency therapeutic interventional radiology.
Acute LGIB: Management algorythm

10. Moderate severe bleeding
Consider NGT aspirate Bloody NGT aspirate
Risk for UGIB
OGD If +ve treat
accordingly
Most of the cases of LGIB fall in this category & require 1st NGT aspiration & if
+ve bloody aspirate , urgent upper GIT endoscopy.
Acute LGIB: Management algorythm

11. Moderate severe bleeding
NGT not done or –ve
aspirate
Polyethelene
glycol(PEG) solution
laxative for
preparation for
emergency
colonoscopy in few
hours.
Colonoscopy within
12-24 hours
Manage according to
colonoscopic findings
If the NGT aspirate is not bloody or NGT was not inserted, urgent prep with PEG
is needed for urgent colonoscopy within12-24 hours.
Acute LGIB: Management algorythm

12. Moderate severe bleeding
On colonoscopy
bleeding site &
cause is identified
so treat as
appropriate.
If the colonoscopy identifies the site/cause of bleeding the problem is solved
Acute LGIB: Management algorythm

13. Moderate severe bleeding
If On colonoscopy
there is visual
impairment because
of ongoing bleeding
Angiography.
If on colonoscopy there was visual impairment due to bloody field urgent
angiography is indicated fordiagnosis & therapy.
Acute LGIB: Management algorythm

14. Moderate severe bleeding
On colonoscopy
bleeding site not
identified but
bleeding had
stopped
OGD
Or
Repeat colonoscopy
Or
SI evaluation
/Or
Others( RBC
scan,angiography)
for rebleeding.
If on colonoscopy the bleeding had stopped & no lesion was identified, upper
GI endoscopy is considered(if had already been done) or RBC scan/angigraphy
Is done fordiagnosis/treatment specially if bleeding recurred.
Acute LGIB: Management algorythm