This document discusses gastrointestinal bleeding, including: - Gastrointestinal bleeding can arise from any location in the GI tract and represents the initial symptom of GI disease in 1/3 of patients. - Clinical presentations of GI bleeding include hematemesis, melena, hematochezia, occult bleeding, and symptoms of blood loss/anemia. - Common causes of upper GI bleeding are peptic ulcers and esophageal varices, while diverticulosis and colon polyps are common causes of lower GI bleeding. - The approach to a patient with GI bleeding involves stabilizing their hemodynamic status, identifying the source of bleeding, stopping active bleeding, treating the underlying cause, and preventing recurrent

1. Gastrointestinal Bleeding

2. • UGIB : Any blood loss from a gastrointestinal
source above the ligament of Treitz.
• LGIB:Any bleeding that occurs distal to the
ligament of Treitz .

3. Gastrointestinal Bleeding
• Etiopathogenesis
• Clinical Presentation
• Approach to Management

4. Gastrointestinal Bleeding
• Can arise anywhere
along the GI tract.
• Represents the initial
symptom of GI
disease in 1/3 of all
patients.

5. Sources of GI Bleeding
UGI
Source of
Bleeding
LGI
Source of
Bleeding
7/9/2023 5

6. Clinical Presentation:5 ways
1. Hematemesis
2. Melena
3. Hematochezia
4. Occult GI bleeding
5. Symptoms of blood loss or Anemia
7/9/2023 6

7. Hematemesis

8. Clinical Presentation:5 ways
• Hematemesis: Vomiting of blood.
• Can be either gross blood & blood clots
(Rapid bleeding )
• “Coffee-ground” emesis (Chronic
bleeding.)
• Bleeding from the oropharynx to the
ligament of Treitz.

9. Clinical Presentation:5 ways
 Melena: Passage of black ,tarry ,Foul smelling
stool caused by digested blood
 Usually the result of severe upper GI bleeding.
 Melena without hematemesis is caused by
severe bleeding distal to the ligament of Treitz.

10. Gastrointestinal Bleeding
 50-60 mL of blood in the GI tract produces
melena.
 Melena can persist from 5-7 days
 Positive fecal occult blood test up to 3
weeks.

11. Melena

12. Clinical Presentation:5 ways
 With upper GI blood loss blood urea nitrogen
levels may be elevated to 30-50 mg/dL.
 BUN: Creatinine ratio greater than 36:1 likely
represents blood loss from an upper GI source.

13. Clinical Presentation:5 ways
Hematochezia:
Passage of bright red or maroon blood
from rectum
7/9/2023 13

14. Clinical Presentation:5 ways
Occult it GI Bleeding:
• Absence of overt bleeding
• Presence of iron deficiency
• Positive fecal occult blood test
Symptoms of Anemia:
• Light headedness
• Syncope
• Angina
• Shortness of breath
7/9/2023 14

15. Upper GI Source of bleeding

16. Upper GI Source of bleeding

17. Upper GI Source of bleeding
• Peptic ulcers are the most
common cause of upper
GI bleeding
• 50% of cases
• H.pylori
• NSAID
7/9/2023 17

18. Upper GI Source of bleeding
Eosophageal Varices
 Varices- Bleeding
esophageal varices in
the presence of liver
disease :10% of upper
GI bleeds
 Life threatening
 High mortality rate.
 Alcoholi c Liver disease
with portal hypertension
7/9/2023 18

19. Upper GI Source of bleeding
Mallory –Weiss tear
• Vomiting
• Retching
• Cough in alcoholic
patient
• Bleeding from tears
at GE junction
• Usually stops
spontaneously in
90% cases

20. Erosive Gastritis
• Endoscopically
visualized
hemorrhages,
erosions ,mucosal
lesions
• Do not cause major
bleeding
• NSAID
• Alcohol
• Stress

21. Lower GI Bleeding

22. Lower Gastrointestinal Bleeding
 Small bowel :10-15% of all lower GI
bleeds.
 Usually a diagnosis of exclusion.
 Meckel’s diverticulum
 Crohn’s disease
 Intussusception
 Neoplasm
 Vascular malformation
 Polyps

23. Diverticulosis

24. Lower Gastrointestinal Bleeding
 Colon:
 Polyps or Neoplastic disease
 Larger bleeds:
 Diverticuli orAngiodysplastic lesions
 Ulcerative colitis- Usually cause chronic
bloody diarrhea, but massive bleeds can occur

25. Colonic Polyps

26. Malignancy
• Colon Carcinoma

27. Rectal and Anal Bleeding
 Fresh red blood on the exterior of stool
• Hemorrhoids
• Fissures
• Proctitis.
 Bleeding that drops into the toilet water
is most likely the result of fissures or
hemorrhoids.

28. Hemmorrhoids

29. Approach to the patient

30. Knowing the site of bleeding is
more important than knowing the
cause

34. Blood in Gastrointestinal tract ?????
• Goals of Bedside Evaluation:
• HematemesisVs Hemoptysis
• UGI from LGI bleed

36. WHERE IS IT FROM
GASTRO INTESTINAL TRACT RESPIRATORY TRACT
Dark red or brown Bright red
In clumps & Mixed with food Foamy, runny & Mixed with mucous
Acidic pH Alkaline pH
Abdominal discomfort
Nausea
Retching before and after episode
Chest pain,
Warmth or gurgling over the chest
Persistent cough
HX of preexisting GI diseases,
Alcohol ,NSAID
Smoker ,PHXTB ,Chronic Respiratory
Diseases

37. Clinical Presentation correlates not
with location but with the rate of
transit
•Hematemesis almost always UGI
•Hematochezia 3/4 patient will have
a LGI source
•Melena more likely UGI than LGI

38. Acute GI bleeding

40. Physical examination
Presence of orthostatic hypotension is
independently associated with increased
mortality

41. Classes of hemorragic shock
Class I Class II Class III Class IV
Blood loss < 750 cc 0-
15%
750-1500
15-30%
1500-2000
30-40%
>2000cc
>40%
HR Normal
PP Normal
BP Normal Normal
UOP Normal Normal Decreased Negligible
Mental Normal Anxious Confused Lethargic
Fluid Crystalloid Crystalloid Crys+blood Crys+blood

42. ….Best friend …..
NG Aspiration

43. Diagnostic Studies: NG Aspiration
• Nasogastric aspirate:
• Determines the status of UGI bleeding
• Gives indirect information in LGI bleeding
• Bright red/clots – active UGI bleed
• Coffee-grounds – slow bleeding, oozing, stopped
• Clear – indeterminate (16% still bleeding)
• Bilious – UGI bleeding has stopped

46. Resuscitation
• Type and cross-match most important
• Complete blood count and Hematocrit
• Initial HCT won’t reflect current blood loss
• BUN
• ECG

47. RX Options
• Begin resuscitation immediately for GIB
associated with:
• Low BP
• Tachycardia
• Syncope
• Angina
• 2 IVs & Crystalloid
• Monitor (VS, Mental Status, Urine Output)

48. RX Options: Transfusion
• Transfusion packed Red Blood Cells:
• Hemoglobin 8 g/dl or Hematocrit 25%
• Brisk active bleeding
• Cardiopulmonary symptoms
• Cardiopulmonary co-morbidity

49. RX Options: Transfusion
• Do not Decide about BT in acute bleeding on
lab reports only
• Hemoglobin and Hematocrit lag bleeding by 24
hours
Decide about BT on Hemodynamic status

50. RX Options :
Vasopressin & Somatostatin analogs
• Somatostatin/Octreotide/Vasopressin:
 Used in variceal upper GI bleeding
 Reduces portal pressure by specific relaxation of
mesenteric vascular smooth muscle
 Useful when endoscopy is unavailable or will be
delayed

51. RX Options
• Gastric acid secretion inhibition (PPI’s):
• High dose Omeprazole /Pantoprazole (80 mg IV
bolus) in bleeding peptic ulcers

52. RX : Balloon Tamponade
• For treatment/temporizing
esophageal variceal
hemorrhage
• Inferior to endoscopy as
primary treatment
• Frequent adverse
reactions
• Mucosal ulceration
• Esophageal/gastric rupture
• Asphyxiation

53. Treatment Options:
Endoscopy(if available)
Diagnostic and
therapeutic
Identifies lesion 95% of
time

54. Endoscopic Banding

55. Endoscopic Sclerotherapy
Intravariceal Paravariceal

56. Treatment for LGIB
• 85% stop spontaneously
• Mortality is lower than with UGIB (< 5%).

58. Acute GI Bleeding
Immediate Assessment
Stabilization of hemodynamic status
Identify the source of bleeding
Stopping the active
bleeding
Treat the underlying
Cause
Prevent recurrent bleeding

59. …..Wishing you all a very happy
New Year Ahead ……..
• …..Success in life
depends upon
maintaining
delicate balance
between is attitude
and aptitude…. !