Simple and Algorthymic approach ,covering all aspects of gastrointestinal hemorrhage. A concise discussion of the diagnostic approach to obscure bleeding. Fundamental principles of initial evaluation and management followed with a welldefined and logical approach to the patient with GI hemorrhage is outlined.

1. “Approach to a patient with GI
Hemorrhage”
 Dr.Bajrang Bawliya
 Dept. of Surgery
 Sir H.N. Reliance foundation
hospital, mumbai
 DNB General surgery Resident

2.  GI Haemorhage can be TRIVIAL (per rectal
bleeding in case of fissure in ano) or MASSIVE
(variceal bleeding)
GI bleeding can occur anywhere from Mouth
to Anus

3. Site of
Bleeding
Upper GI
bleeding
Lower GI
bleeding

4. Forms of GI bleeding
Hematemesis
Vomiting of blood - s/o
Upper GI bleeding
a) Bright red colour
b) Coffee Ground
Vomitus
Melena
Black, Tarry, Foul
smelling stool
- Usually s/o Upper GI
bleed
- Can also be seen in
Lower GI bleed
Hematochezia
Bright red blood may or
may not be mixed with
stool
s/o Distal Colonic
Pathology

5. Melena Versus Stool of patient on Iron supp.
Melena – Black,
Tarry, Foul
smelling stool
Guaiac test -
Positive
Greenish Black
stool with h/o
iron suppl.
Guaiac test -
Negative

6. Nomenclature
Occult bleeding
Bleeding which is not visible to
patient , which is suspected when
patient presents with anaemia
Obscure bleeding
Bleeding that PERSIST or RECUR
even after negative finding in
endoscopy

8. Approach to a patient with GI haemorrhage
INITIAL ASSESSMENT AND RESUSCITATION
A) Airway, Breathing and Circulation
B) Magnitude of bleeding - by history and vitals
C) Monitoring of vitals
D) Laboratory evaluation - cbc, blood grouping and cross matching, lft, coag. profile
HISTORY AND PHYSICAL EXAMINATION
A) Site of bleeding - Upper/Lower GI bleed (hematemesis/melena/hematochezia)
B) Cause of bleeding
C) Any past history of such episode or h/o patient on any
medications(NSAIDs,SSRI,Salicylates)
D) Keep monitoring vitals
LOCALIZE BLEEDING
A) Endoscopy –
EGDscopy/Colon
oscopy
TREATMENT OF CAUSE
A) Pharmacological therapy
B) Endoscopic therapy
C) Angiographic therapy
D) Surgery

9. RESUSCITATION
Feeble pulse, Tachycardia, Hypotension (Hypovolemic Shock)
Needs Aggressive
management
A) 2 large bore (16G, 18G) IV cannula
B) Start Bolus fluid with Crystalloid – RL
C) Foley’s Catheter – monitor urine output
D) Oxygen supplementation – maximize oxygen carrying capacity
E) Blood Transfusion
F) FFP transfusion

10. Overview of a ACUTE GI HAEMORRHAGE
History and Findings s/o Upper/Lower GI bleed
Can put Nasogastric tube to confirm diagnosis
Upper GI bleed Lower GI bleed
Early Upper GI Scopy
(within 24 hrs)
Diagnostic
Treatment
accordingly
Non-Diagnostic
Further decision is taken
depending on VOLUME of
bleeding
Slow
bleeding
Massive
bleeding
COLONOSCOPY ANGIOGRAPHY
Diagnostic Non-Diagnostic
a) RBC scan
b) CT angiography
c) Capsule Endoscopy
Slow
bleeding
Massive
Bleeding with
stable patient
ANGIOGRAPHYRBC Scan

12. Causes of UPPER GI Haemorrhage
NON-VARICEAL
bleeding (80%)
VARICEAL
bleeding(20%)
1) m/c – GASTRIC & DUODENAL
ULCER (30-40%)
2) Gastritis/Duodenitis (20%)
3) Mallory Weiss tears (5-10%)
4) Esophagitis (5-10%)
5) A-V malformation (5%)
6) Tumor (5%)
7) Others
1) m/c – GASTRO ESOPHAGEAL
VARICES (>90%)
2) Hypertensive Portal
Gastropathy (<5%)
3) Isolated Gastric Varices - rare

13. Management of UPPER GI BLEEDING
UPPER GI SCOPY
Difficult to
diagnosis
Patient
STABLE
ANGIOGRAPHY
UNSTABLE
Non-variceal
bleeding –
PEPTIC ULCER
Disease
VARICEAL
BLEEDING
ENDOSCOPIC THERAPY
SURGICAL
INTERVENTION
Diagnosis made
- Due to EXCESSIVE BLOOD
impairing visualization
If bleeding PERSIST YES
NOMonitor REBLEEDINGYES
REPEAT ENDOSCOPY REBLEEDING + YES
NO Monitor REBLEEDING YES
SURGERY

14. ENDOSCOPIC THERAPY FOR PEPTIC ULCER
BLEEDING
1) Inj. Adrenaline (1;10,000) is injected around
bleeding ulcer f/b TAMPONADE f/b
ELECTROCOAGULATION with cautery, laser or
APC(Argon Plasma Coagulation)
2) If there is a visualised vessel than HEMOCLIP
is used

15. FORREST CLASSIFICATION
• It is a classification used to describe peptic ulcer
and risk of rebleeding
• Class 1a,1b and 2a – High risk for rebleed
• Class 2b – Intermediate risk
• Class 2c and 3 – low risk

16. Management acc. to forest classif.
• Class 1a, 1b and 2a – as described earlier
• Class 2b – Endoscopicaly clot is dislodged and observed
• Class 2c and 3a – observed

17. SCORES
• This scores are used to identify the individuals who are at HIGH RISK for
MAJOR BLEEDING and have HIGH MORTALITY and so they need aggressive
management.
• The Rockall score utilizes clinical as well endoscopic findings , range- 0 to
11 ,higher score higher risk
• Blatchford score ,lesser used , maimum score - 23
Blatchford score

19. Indication of Surgery in PUD
1. Failure of Endoscopic approach to control
bleeding.
2. Recurrent hemorrhage after initial attempt of
Endoscopic control.
3. Hemodynamically unstable patient inspite of
receiving >6 units of blood transfusion.
4. Continuous slow bleeding with requirement of
transfusion >3 units per day
5. Shock a/w Recurrent hemorrhage

20. Surgery done for Gastric Ulcer
1. Gastrotomy f/b Suture Ligation – has 30%
chance of rebleed.
2. Simple Excision of Ulcer – as all Gastric ulcer
have 10% chances of Malignancy so excision is
consider better than suture ligation. Has 20%
chance of rebleed.
3. Distal Gastrectomy - considered in cases of
Recurrent PUD with bleeding
Ulcers larger than 2 cm, posterior duodenal ulcers, and gastric ulcers
have significantly higher risk of rebleeding

21. Surgery done for Duodenal Ulcer
1. Longitudnal duodenotomy /
Duodeno-pylomyotomy f/b
suture ligation
- If ulcer is on posterior duodenal
wall than there are high chance of
REBLEED due to involvement of
branches of GASTRO-DUODENAL
or PANCREATICO-DUODENAL
ARTERY.
- For this vessel is ligated proximal
as well as distal to ulcer with “U”
STITCH underneath ulcer

23. Infectious – Herpes Esophagitis
• Complaints are Melena + Anemia > Hematemesis
• TOC – Endoscopic electocoagulation

24. Mallory Weis tears
• it is a mucosal and submucosal
tear seen near GE jn. along lesser
curvature.
• mostly seen in patient after
binge alcohol drinking due to
intense retching and vomitting.
• Also seen in patient with
multiple episode of emesis.
• Rx - Usually doesn’t require any
active management, sometimes
may require endoscopic
compression.

25. Dieulafoy lesion
• It is a VASCULAR MALFORMATION
• Seen on LESSER CURVATURE within 6cm of GE junction
• Represent rupture of LARGE vessel(1-3mm) in Submucosa
• TOC – Endoscopic electrocoagulation – successful in 80 % - if fails – Angiographic
embolization – if fails – Gastrotomy f/b hemostasis and suturing of mucosal defect –
if fails – partial gastrectomy.

26. GAVE – Gastric Antral Vascular Ectasia
• Also k/a WATERMELON stomach
due to its endoscopic
appearance.
• This appearance is due to
DILATED VENULES in ANTRAL
part of stomach converging
longitudinally towards pylorus
• Anemia+Melena > Hematem.
• TOC – APC (Argon Plasma
Coag.)

28. Iatrogenic causes
Post Procedural-
• Nasogastric tube erosions,endoscopic
biopsy,endoscopic polypectomy,endoscopic
sphincterectomy
• Percutenous endoscopic gastrotomy (PEG)
• Percutenous transhepatic procedures

30. VARICEAL BLEEDING suspected
ABC ensured and Resuscitation done
Start on OCTREOTIDE Infusion
Upper GI scopy
Variceal bleeding
diagnosis confirmed
Endoscopic Band ligation > Sclerotherapy (SE-Stricture,
perforation, mediastinitis)
Bleeding Stopped
Balloon tamponade
(sengstaken –
blakemore tube) or
Self expanding
Esophageal Stents
are used
TIPS (Transjugular
Intrahepatic
Portosystemic Shunt
• Continue Octreotide
• Continue IV antibiotics
• Repeat Band Ligation after
14 days
YES NO
Still
bleeding

31. Endoscopic Procedures
Band Ligation Sclerotherapy
Sclerosant – Ethanolamine, Sodium
tetradecyl Sulphate

32. Balloon tamponade
it is done with SENSTAKEN BLAKEMORE tube

34. Portal Hypertensive Gastropathy
• It is a disease involving diffuse
gastric mucosa making it friable
with ectatic blood vessel at
some places
• Shows Mosaic pattern and
snake skin-like appearance with
cherry-red spots on Endoscopy
• Difficult to manage
endoscopically due to diffuse
nature of disease
• TOC – PPI , if fails than TIPS is
the only option

37. Causes of LOWER GI Haemorrhage
COLONIC
pathology(95%)
SMALL BOWEL
pathology (5%)
1) m/c – DIVERTICULA (30-40%)
2) Ano-rectal disease (10-15%)
3) Ischemia (5-10%)
4) Neoplasia (5-10%)
5) Infectious colitis(3-8%)
6) IBD (3-5%)
7) Angiodysplasia (3%)
8) Radiation Proctitis (1-3%)
9) Others (1-5%)
10) Unknown – (10-25%)
1) Angiodysplasia
2) Meckels Diverticulum
3) Ulcers/erosions
4) Chrons
5) Radiation
6) Neoplasm
7) Aorto-enteric fistula

38. Colonic Diverticula- m/c cause of lower
GI bleed
• m/c on LEFT colon
• But RIGHT bleeds>left
• Bleeding is from NECK of diverticula
• 75% bleed stops spontaneously
• TOC – Colonoscopic injection of Adr.
+/- electocoagulation +/- clip -- if
fails – Angiography f/b embolization
– if fails – Exploration with colonic
resection
• Mesenteric Angiography
Selective angiography, using either the superior or
inferior mesenteric arteries, can detect
hemorrhage in the range of 0.5 to
1.0 mL/min and is generally employed only in the
diagnosis of ongoing hemorrhage.
It can be particularly useful in identifying
the vascular patterns of angiodysplasias. It may also be
used for localizing actively bleeding diverticula.

39. Ano rectal pathology causing Lower GI
Bleeding
• Anal fissures-rarely cause large amount of blood
loss,bleeding usually ceases spontaneously
• Hamorrhoids- 2-9 % cases of lower GI bleed ,fresh
blood seen on tissue paper or bowl and around the
stools.Mx-Rubber band ligation,injection
Sclerotherapy,infrared coagulation ,in refractory cases
surgical haemrrhodectomy
• Solitory rectal ulcers- arises as result of local ischemia
due t internal rectal prolapse , rarely causes bleeding
• Anorectal varices-arise in patients of portal
hypertension and can bleed in 18 % of those patients
• Colorectal Neoplasia

40. Obscure Lower GI bleeding
• Bleeding persisting or recurring after negative
esophagogastroscopy and colonoscopy occurs
in approximately 5 % of cases is termed
oscure bleeding
• Often result due to angiodyplastic
lesions,Dieulafoy’s lesions , Mekel’s
Diverticula ,small bowel Neoplasm

41. Investigations used in neg.
Colonoscopy
1. Radionuclide tagged RBC scan
• Patient’s RBC’s are
withdrawn from the patient
and labelled with Tc-99 and
Re-injected in patient.
• Most sensitive but less
accurate
• Labelled RBC’s extravasates
in Bowel and detected on
scan
• Diagram – shows filling of
bulbous structure, probably
caecum at 20 min

42. 2.ENTEROSCOPY / SMALL BOWEL ENDOSCOPY
• Initially scope which were
available were limited upto
50-70 cm from ligament of
Treitz.
• Nowadays DOUBLE-
BALLOON endoscopy is used
to visualize whole of the
small bowel

43. 3. CT - Enterography
• It is CT scan after giving Oral
conrast with IV contrast
4. Small bowel Enteroclysis
• Here contrast is given
through tube, movement of
contrast dye is visualised
• Not done nowadays

44. 5. Video Capsule Endoscopy
• A small capsule which
has video camera in it
is given to patient to
swallow and images
are taken all through
the parts of bowel.
• It is patient friendly
but time consuming
and non-therapeutic

45. 6. Intra-operative endoscopy
• Reserved for patient to diagnose bleeding
intraoperatively in an hemodynamically
unstable patient.