3. Introduction
Gastrointestinal bleeding (GIB) common clinical
problem
GIB traditionally divided into either upper, lower
Or acute and chronic
Upper gastrointestinal bleeding (UGIB):
bleeding from any source proximal to ligament of
Treitz
Lower gastrointestinal bleeding (LGIB):
bleeding from any source distal to ligament of Treitz
4. UGIB is more common than LGIB;
UGIB approx. 67/100,000 population
LGIB approx. 36/100,000 population
LGIB:
More common with increasing age
More common in men
mortality rate 2 - 4%
Epidemiology
5. GIB- Presentation
Haematemesis: Vomiting of blood whether fresh
and red or digested and black.
Melaena: Passage of loose, black tarry stools with
a characteristic foul smell.
Coffee ground vomiting: Blood clot in the
vomitus.
Hematochezia: Passage of bright red blood per
rectum, usually indicates bleeding from the
lower GI tract, but can occasionally be the
presentation for a briskly bleeding upper GI
source
6. GIB- Presentation
The presence of frank bloody emesis suggests more
active and severe bleeding in comparison to coffee-
ground emesis.
Lower GI bleeding classically presents with
hematochezia, however bleeding from the right
colon or the small intestine can present with melena.
Bleeding from the left side of the colon tends to
present bright red in color, whereas bleeding from
the right side of the colon often appears dark or
maroon-colored and may be mixed with stool.
7. GIB- Presentation
Other presentations which can accompany
GIB include hemodynamic instability,
abdominal pain and symptoms of anemia
such as lethargy, fatigue, syncope and angina.
Patients with acute bleeding usually have
normocytic red blood cells. Microcytic red
blood cells or iron deficiency anemia suggests
chronic bleeding.
8. Occasionally, hemoptysis may be
confused for hematemesis or vice versa.
Ingestion of bismuth containing products
or iron supplements may cause stools to
appear melanic.
Certain foods/dyes may turn emesis or
stool red, purple, or maroon (such as
beets).
Differential Diagnosis
9. Majority of patients with UGIB will spontaneously
cease.
70-80% will stop within first 48 hrs of onset; of those
10-20% will have recurrence of UGIB. At initial
presentation ~20% will continue to bleed.
Mortality greatest in these patients and also patients
that have recurrent bleeding
UGIB
10. Can divide causes into; variceal and non-
variceal
Despite advances in diagnosis and treatment,
mortality of UGIB remains from 5 – 14%
Mortality higher in patients > 60 yrs old and in
patients with multiple comorbid conditions
Introduction
Etiology- UGIB
12. Dieulafoy’s lesion (bleeding dilated vessel that erodes through
the gastrointestinal epithelium but has no primary ulceration;
can any location along the GI tract).
Gastric Antral Vascular Ectasia (GAVE; also known as
watermelon stomach).
Cameron lesions (bleeding ulcers occurring at the site of a
hiatal hernia).
Post-surgical bleeds (post-anastomotic bleeding, post-
polypectomy bleeding, post-sphincterotomy bleeding).
Hemobilia (bleeding from the biliary tract).
Miscellaneous
13. 20-30% of patients will have two or more
diagnoses of UGIB.
No disease is found in 10-15% of patients
(prognosis is excellent).
bleeding peptic ulcer disease most common
etiology and is also the most widely studied
UGIB
14. LGIB
Diverticulosis (colonic wall protrusion at the site of
penetrating vessels; over time mucosa overlying the vessel can
be injured and rupture leading to bleeding).
Angiodysplasia
Infectious Colitis
Ischemic Colitis
Inflammatory Bowel Disease
Colon cancer
16. Monitor hemodynamic status; Look for signs of
hemodynamic instability:
Resting tachycardia: associated with the loss of less than 15%
total blood volume
Orthostatic Hypotension: carries an association with the loss of
approximately 15% total blood volume
Supine Hypotension: associated with the loss of approximately
40% total blood volume
UGIB- Initial Evaluation
17. Confirm UGI source of bleeding by
history (hematemesis – fresh blood or coffee
ground emesis, melena)
Nasogastric aspiration is 80% sensitive for
actively bleeding UGI source
False negative aspirates occur when the tube is
improperly positioned or when reflux of blood
from a duodenal source prevented by
pylorospasm or obstruction
UGIB- Initial Evaluation
18. Complete blood count
Hemoglobin/Hematocrit
INR, PT, PTT
Liver and renal function tests
UGIB- Lab Evaluation
19. UGIB- Treatment / Management
Risk Stratification
Specific risk calculators attempt to help identify
patients who would benefit from ICU level of care;
most stratify based on mortality risk.
The Rockall Score calculate the mortality rate of upper
GI bleeds. There are two separate Rockall scores; One
is calculated before endoscopy and identifies pre-
endoscopy mortality, whereas the second score is
calculated post-endoscopy and calculates overall
mortality and re-bleeding risks.
20. UGIB- Treatment / Management
Acute management of UGIB typically involves;
1. Assessment of the appropriate setting
2. Resuscitation
3. Supportive therapy
4. Investigating the underlying cause and attempting
to correct it.
21. UGIB- Treatment / Management
Setting
ICU; Patients with hemodynamic instability,
continuous bleeding, or those with a significant risk
of morbidity/mortality should undergo monitoring in
an intensive care unit to facilitate more frequent
observation of vital signs and more emergent
therapeutic intervention.
22. UGIB- Treatment / Management
Setting
Most patients with GI bleeding will require
hospitalization. However, some young, healthy
patients with self-limited and asymptomatic
bleeding may be safely discharged and
evaluated on an outpatient basis.
23. UGIB- Resuscitation
Nothing by mouth
Adequate IV access - at least two large-bore
peripheral IVs or a centrally placed.
Provide supplemental oxygen if patient
hypoxic (typically via nasal cannula, but
patients with ongoing hematemesis or altered
mental status may require intubation).
24. UGIB- Resuscitation
IV fluid resuscitation (with Normal Saline or
Lactated Ringer’s solution)
Type and Cross matching.
Transfusions:
RBC transfusion; typically started if hemoglobin is
< 7g/dL, including cardiac patients.
Platelet transfusion; started if platelet count <
50,000.
Prothrombin complex concentrate; if INR > 2
25. UGIB- Resuscitation
Medications;
PPIs: Bolus (80 mg), followed by maintainence
(8 mg/kg/hr)- 3-5 days-significant benefit in
decreasing recurrent bleeding.
Vasoactive medications: Somatostatin and its
analog octreotide can be used to treat variceal
bleeding by inhibiting vasodilatory hormone
release.
Erythromycin: Given to improve visualization at
the time of endoscopy.
26. UGIB- Resuscitation
Antibiotics; Considered prophylactically in
patients with cirrhosis to prevent SBP, especially
from endoscopy
Anticoagulant/antiplatelet agents; Should be
stopped if possible in acute bleeds. Consider the
reversal of agents on a case-by-case basis
dependent on the severity of bleeding and risks
of reversal.
27. UGIB- Resuscitation
Placement of a sengestaken tube should be
considered in patients with hemodynamic
instability/massive GI bleeds in the setting of
known varices, which should be done only once
the airway is secured.
This procedure carries a significant
complication risk (including arrhythmias,
gastric or esophageal perforation) and should
only be done by an experienced provider as a
temporizing measure.
28. UGIB- Endoscopy
Can be diagnostic and therapeutic. It is the test
of choice for identifying and treating the
bleeding lesion
Allows visualization of the upper GI tract
(typically including from the oral cavity up to
the duodenum) and treatment with injection
therapy, thermal coagulation, hemostatic
clips/bands or band ligation.
No role for barium studies in acute UGIB
29. UGIB- Endoscopy
Greatest benefit in the ~20% of patients with
continued or recurrent bleeding
Improve morbidity and mortality: mortality
decreased by nearly 30%.
Active bleeding can be controlled in 85-90% of
patients, with less than 3% complication rate.
Should be done within 12-24 hrs.
30. UGIB- Endoscopy
Endoscopic Management
Several endoscopic therapeutic techniques available
to attempt hemostasis in patients with UGIB
Thermal
Multipolar electrocautery /bipolar
electrocautery
Argon plasma coagulation
Injection
Epinephrine
Mechanical
Band Ligation
Hemoclips (Endoclip)