This document provides information about the diagnosis and management of gastrointestinal bleeding. It discusses: 1) The aim is to understand GI bleeding and provide proper care to patients. Objectives include defining GI bleeding, identifying upper and lower GI bleeding, understanding causes and symptoms, and recognizing diagnostic tests and treatments. 2) GI bleeding can occur anywhere along the gastrointestinal tract from mouth to anus. Upper GI bleeding makes up 70% of cases and lower GI bleeding 30%. Etiologies, signs, symptoms, diagnostic evaluations, and management are discussed for both upper and lower GI bleeding. 3) Workup may include history, physical exam, blood tests, endoscopy, angiography, and imaging. Management focuses on res

1. SNDT WOMENS UNIVERS
L.T.COLLEGE OF NURSIN
BAIJAYANTI NATH.
M.SC. NURSING 1ST YEAR.

2. AIM &OBJECTIVES:
: AIM: After completion of the seminar the group will be
able to understand the topic GIbleeding in a and can able
to provide proper care to the GI bleeding patient.
 OBJECTIVES:
 At the end of the topic the group will be able to:
 Define GI bleeding.
 Identify upper and lower GI bleeding.
 Understand the etiology and pathophysiology of the GI
bleeding.
 Classify the GI bleeding.
 Recognize the sign and symptoms of the upper and lower
GI bleeding.
 Recognize the different diagnostic evaluation.
 Understand the medical ,surgical and nursing
management of GI bleeding.

3. INTRODUCTION
 Gastrointestinal bleeding is among the most common
gastrointestinal disorder.gi bleeding is not just a
gestrodudenal disorder but may occur in anywhere in
the alimentary tract. Bleeding is a symptom of upper
and lower gi disorder. It may be oblivious in stool or
occult(hidden).

4. DEFINITION
 Gastrointestinal bleeding (GI bleed), also known
as gastrointestinal hemorrhage, is all forms
of bleeding in the gastrointestinal tract, from the
mouth to the rectum. When there is
significant blood loss over a short time, symptoms may
include vomiting red blood, vomiting black blood,
bloody stool, or black stool.

5. ETIOLOGY AND PATHOPHYSIOLOGY
 Trauma anywhere in the GI tract.
 Erosion or ulcer.
 Rupture of the enlarge vein.
 Inflammation and infection in alimentary tract.eg-
esophegitis,gastritis etc
 alcohol and drug consumption.eg-NSAID aspirin
containing compounds, anticuagulent.
 Vascular lesion disorder.
 Anal disorder.

6. CLASSIFICATION OF GI BLEEDING:
 Upper GI Tract Bleeding
 Proximal to the Ligament of Treitz
 70% of GI Bleeds
 Lower GI Tract bleeding
 Distal to the Ligament of Treitz
 30% of GI Bleeds

7. UPPER GI BLEEDING:
 UPPER GI bleeding is defined as bleeding from
gastrointestinal tract proximal to ligament of Trietz.
 It usually manifests as hematemesis or melena, and
when severe, may even lead to hematochezia.
 Clinical guidelines are recommended to predict out -
come, including rebleeding, and mortality.
 Stigmata of a recent hemorrhge are endoscopic finding
that predict outcome.

8. INCIDENCE:
 170 patients/ 100,000 population /year.
 40% due to peptic ulcer(Most common).
 80% are self-limited.

9. RISK FACTORS
 NSAID use
 H. pylori infection
 Increased age
 Upper GI Bleeding accounts for approximately 350,000
hospitalizations per year.

10. ETIOLOGY OF UPPER BLEEDS
 Duodenal Ulcer-30%
 Gastric Ulcer-20%
 Varices-10%(Vague right upper quadrant pain, fever,
nausea, vomiting, ascites, edema.
 Features of hepatic failures )
 Gastritis and duodenitis-5-10%
 Esophagitis-5%
 Mallory Weiss Tear-3%
 GI Malignancy-1%
 Dieulafoy Lesion
 AV Malformation-angiodysplasia

11. SIGNS AND SYMPTOMS
 Signs and symptoms of acute upper GI bleeding[1] include the
following:
 Features due to blood loss :
 1.Haemetemesis,malena or haematochezia , Hyperactive bowel
sound.
 2.H/O CLD presenting with shock.
 3. H/O ESRD with sudden derange RFTs.
 4. Features of co-morbid illnesses - IHD, COPD,
CHF,SEPTICEMIA,PT ON VENTILLATORY SUPPORT.
 On evaluation:
 1. Anemia
 2.Orthostatic changes of BP and HR
 3.Shock

12. OTHERS:
 Hematemesis
 Melena
 Hematochezia
 Syncope
 Presyncope
 Dyspepsia
 Epigastric pain
 Heartburn
 Diffuse abdominal pain
 Dysphagia
 Weight loss
 Jaundice

13. DIAGNOSIS
HISTORY EXAMINATION
EMERGENCY ENDOSCOPY???

14.  History
 Helpful to find out the site and cause
 History suggestive of acid – peptic disease
 Alcoholic liver diseases / chronic hepatitis / Cirrhosis
 History of anticoagulant / anti platelets / NSAIDS /
Alcohol binge intake / steroids
 History of Coagulation disorder / Blood Dyscrasias
 History of Epistaxis or Hemoptysis to rule out the GI
source of bleeding
 Patients of CVA, BURN, Sepsis, Head Trauma may
have stress ulcers

15. ON EXAMINATION
 VITALS
 Pulse = Thready,BP = Orthostatic Hypotension
 SKIN changes
 Cirrhosis – Palmer- erythema, spider angioma
 Bleeding diasthasis – Purpura /Echymosis
 Coagulation Disorder – Haemarthrosis, Muscle
Hematoma
 ENT :- Look for clots (To rule out epistaxis P.N BLEED)
 P/A :-
 Liver , Spleen, Caput Medusa = Cirrhosis
 Epigastric Tenderness = APD/ Ulcer
 Respiratory, CVS, CNS  For comorbid diseses

16. Diagnostic Workup
 CBC
 Bleeding &Coagulation profile
(BT, CT,PT, a PTT)
 Liver Function Test
 Complete S. Biochemistry
 Relevant lab test for underlying
disease
BLOOD INV. ENDOSCOPY RADIO-IMAGING
• Barium Meal F.T.
• Arteriography
• USG/ Doppler USG
• Radio nucleotide study
(Tagged RBC scan)

17. Objectives in Acute GI bleeding:
Immediate Assessment
Stabilization of hemodynamic status
Identify the source of bleeding
Stopping the active bleeding
Treat the underlying
Prevent recurrent bleeding

18. AUGIB
Rapid Assessment
Monitor Hemodynamic Status
Fluid Resuscitation
Ryle;s tube for Gastric Lavage
Self Limited Hemorrhage (80%) Continued bleeding (10-25%)
Urgent endoscopy
Recurrent Hemorrhage
Elective Endoscopy
(With in 24 – 48 hours)
Definitive Therapy
(If Necessary)
Site not localized Localized
Further Assessment
(Extended EGD,
Radio-isotope scan,
Arteriography,
Exploratory
Laprotomy)
Definitive
Therapy

19. MANAGEMENT
 Endoscopic therapy: the goal of endoscopic therapy
is to coagulate or thromboses the blood vessels the
blood vessels.
 It is mainly useful to stop bleeding in patient with
sever gastritis varises peptic ulcer,polyps,several
techniques are used, including-
 Thermal probe
 Multipolar bipolar electrocuagulation probe.
 Argon plasma coagulation.
 Neodymium:yttrium-aluminium-garnet-laser.

20. Identify bleeding source
(Pre- requisites for endoscopy):
Bloody endoscopy field
1. Naso-gastric tube(RT. esp. Wide bore) –
 coffee coloured/clots/fresh blood
 aspirate may categorize these pts- Low/ Intermediate/High
2. Gastric Lavage –
 saline with or without H2O2
 prokinetic(erythromycin, metchlopromide) agents may be used.
 color and rapidity of clearing: clear fluid indicates absence of GH
and pt may be subjected for endoscopy.
3. Risk of aspiration (insure airway/ E.T tube).
Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition

21. NASOGASTRIC LAVAGE
 Benefits of lavage :
 Better visualization during endoscopy.
 Give crude estimation of rapidity of bleeding.
 Prevent the development of porto systemic encephalopathy in
cirrhosis.
 Increases PH of stomach and hence decreases clot
desolution due to gastric acid dilution
 During gastric lavage use saline and not use large volume of
to avoid water intoxication.
 Gastric lavage should be done in alert and cooperative
patient to avoid broncho-pulmonary aspiration

22. NASOGASTRIC LAVAGE
 If gastric aspirate either is grossly bloody or yields
coffee ground effort should be made to lavage the
stomach before proceeding to diagnostic or
therapeutic endoscopy.
 The presence of bloody gastric aspirate confirms UGI
Bleed.
 A negative aspirate (16%) does not exclude an upper
bleeding. For Example in case of duodenal ulcer due to
absence of duodenogastric reflux aspirate is clear

23. MEDICAL THERAPY
epinephrine during endoscopy is effective for acute
hemostasis.epinephrine produces tissue edema and ultimately,
pressure on the bleeding. To prevent rebleeding,injection
therapy is often combined with other therapies.
 For variceal bleeding-vasoprasin used to produce
vasoconstriction. It is used in those patient who do not respond
to other therapies and are poor surgical risks. It is administered
systematically in IV or intra-arterial route.
 Histamine receptor blockers or protons pump inhibitors are
administers to decrease acid secretion.eg-renitidine,cimetidine.
 Eg-omeprazole ,pentoprazole.
 Antacids are used to nutrilizes the HCI .eg magnesium
hydroxide,calciumhydroxide,sodium bicarbonate etc.
 Sedatives are sometimes used in restless patient.

24. Surgical therapy:

25. Lower GI bleeding :
bleeding that occurs distal to the
ligament of Treitz.
This includes the last 1/4 of the
duodenum and the entire area of the
jejunum, ileum, colon, rectum and anus.

26. Incidence:
- 20-33% of episodes of gastrointestinal (GI)
hemorrhage.
- annual incidence of about 20-27 cases per
100,000 population.
- The incidence rises steeply with advancing
age.
- 80% resolve spontaneously.
- 25% will re-bleed.

27. Etiology:

28. Etiology:
Diverticular disease
60%
Inflammatory bowel disease
13%
Benign anorectal diseases
11%
Neoplasia 9%
Angiodysplasia
4%
Coagulopathy
3%

29. Categorization of (LGI) bleeding
by intensity:
Massive bleeding
Moderate bleeding
Occult bleeding

33. What is Diverticulosis?

34. Most common site
 Diverticula can occur throughout the colon but are
most common near the end of the left colon referred to
as the sigmoid colon.

35. Risk factors
 increasing age
 constipation
 a diet that is low in dietary fiber
 high intake of meat and red meat
 connective tissue disorders (such as Mara fan
syndrome) that may cause weakness in the colon wall
 hereditary or genetic predisposition

36. What are the symptoms of diverticular disease?
 Most patients with diverticulosis have few or no
symptoms.
 The most common symptoms of diverticular disease
include:
abdominal cramping,
constipation, and
diarrhea.
These symptoms are related to difficulty in passing stool
through the left colon, which is narrowed by
diverticular disease.

37. Complication:
 The most common complication is diverticulitis which
is a condition in which diverticuli in the colon rupture.
Which results in infection in the tissues that surround
the colon
 bleeding.
 Abscess, Perforation, and Peritonitis
Fistula

38. DIAGNOSIS:
 Colonoscopy
 Barium X-rays (barium enemas) can be performed to
visualize the colon. Diverticula are seen as barium
filled pouches protruding from the colon wall.
 ultrasound and CT scan examinations of the abdomen
and pelvis can be done to detect collections of pus.

39.  Inflammatory bowel disease

40. Is a form of inflammatory bowel disease, characterized
by inflammation with ulcer formation in the lining of
colon.

41. rectum
Sigmoid&
descending
colon
Whole
colon
Site of
involvment
Inflammation of the distal
terminal ileum may occur

42. Bleeding per rectum.
- Diarrhea (bloody diarrhea) with mucous.
- Tenesmus, when the disease is confined to the rectum.
-Abdominal discomfort.
- Remissions & exacerbations.
Clinical
picture

43. MANIFESTATIONS

44. ISCHEMIC COLITIS
a medical condition in which inflammation and injury
of the large intestine result from inadequate blood
supply.

45. Common site
affection
Transverse
colon
Splenic
flexure
Site of ischemia

46. ( depend on severity of ischemia)
1-abdominal pain
2-rectal bleeding
3-diarrhea
4-fever.
Clinical
picture

47. Hemorrhoids

48. Predisposing factors:
• Constipation.
• Sitting for long periods of time.
• Obesity.
• Heavy Lifting.

49. Clinical Presentation :
 Patients commonly present to a physician for two
main reasons:
• Bleeding.
• Protrusion.
• Pain.
• Anal Itching.

50. Diagnosis:
• Mainly during the physical examination
by:
I. Inspection of the perianal
region, with careful digital
examination.
II. Anoscopy
III. Staging.

52. Angiodyplasia
 It is a tourtious dilatations of submucosal and mucosal
blood vessels are seen most often in the cecum or right
colon

53. Neoplasm
 Neoplastic bleeding can be from a polyp or carcinoma.
 Colon cancer is the predominant cause of neoplastic
bleeding and is responsible for around 10% of rectal
bleeding in patients older than 50 years.
 The bleeding is usually low-grade and recurrent,
occurring as a result of mucosal ulceration or erosion.
Though neoplastic bleeding can present as bright red
blood per rectum, it is unusual for it to cause massive
colonic bleeding.

54. Coagulopathy
 (also called clotting disorder and bleeding
disorder)
is a condition in which the blood’s ability to clot is
impaired. This condition can cause prolonged or
excessive bleeding, which may occur spontaneously
or following an injury or medical procedures.

55. DIAGNOSIS
 Despite improvement in diagnostic imaging &
procedures, 10-20% of pts with Lower GIT bleeding
have no demonstrable bleeding source.
 Therefore, this complex problem requires systematic
evaluation.

56. A- Initial Evaluation
Patient's history:
-aspirin, vascular disease, past bleeding episodes, liver
cirrhosis, IBD, coagulopathy.
-duration, frequency, stool colour.
Digital rectal examination
Physical examination to assess the severity of
bleeding:
-HR , BP, postural changes.

57. B- Laboratory Tests
CBC
ESR/ CRP
Coagulation profile
Liver function tests
Renal function tests

58. C- Endoscopy
Colonoscopy:
Esophagogastroduodenoscopy:
Small Bowel Visualization

59. Angiography
 Performed after colonoscopy has failed to identify a
bleeding site ,can detect bleeding at a rate of more than
0.5 mL/min.
 In a patient with active GI bleeding, the radiologist first
cannulates the superior mesenteric artery, because
most of the hemodynamically significant bleeding
originates in the right colon. The extravasation of
contrast material indicates a positive study finding. If the
findings from the study are negative, the inferior
mesenteric artery is cannulated, followed by the celiac
artery.

60. Once the bleeding point is identified,
angiography offers potential treatment options,
such as selective vasopressin drip and
embolization.

61.  E. Barium Enema
F. Abdominal Radiography /CT

62.  Resuscitation and initial assessment.
 Localization of the bleeding site.
 Therapeutic intervention to stop bleeding at the site.

63. 1) Resuscitation and Initial Assessment:
 IV access and administration of normal saline.
 Rapid assessment of vital signs, including heart
rate, blood pressure, pulse pressure, and urine
output.
 Routine laboratory studies (CBC, electrolyte levels,
and coagulation studies), blood should be typed
and cross-matched.
 The patient's blood loss and hemodynamic status
should be evaluated, and in cases of severe
bleeding, the patient may require invasive
hemodynamic monitoring .

64.  Patients in shock should receive fluid volume
replacement without delay.
Colloid or crystalloid solutions may be used to achieve
volume restoration before administering blood
products.
Red cell transfusion should be considered after loss of
30% of the circulating volume.

65. 2) Localization of the Bleeding Site
 In patients who are hemo-dynamically stable with mild to
moderate bleeding or in patients who have had a massive
bleed that has stabilized, colonoscopy should be performed
initially. Once the bleeding site is localized, therapeutic
options include coagulation and injection with
vasoconstrictors or sclerosing agents.
 In cases of diverticular bleeding, bipolar probe coagulation,
epinephrine injection, and metallic clips may be used.
 If recurrent bleeding is present, the affected bowel segment
can be resected.
 In cases of angiodysplasia, thermal therapy, such as electro-
coagulation or argon plasma coagulation, is generally
successful.

66. Therapeutic intervention to stop bleeding at the site.
:Colonoscopy
 Colonoscopy is useful in radiation
therapy–induced gastrointestinal (GI)
bleeding and in the treatment of
colonic polyp lesions.
 Endoscopic treatment of radiation-
induced bleeding includes topical
application of formalin, Nd:YAG laser
therapy, and argon plasma coagulation.
 Neoplastic bleeding due to polyps
requires polypectomy. Patients
diagnosed with colonic tumors may
require surgical resection.

67. Vasoconstrictive Therapy :
 In patients in whom the bleeding site cannot be
determined based on colonoscopy and in patients with
active LGIB, angiography with or without a preceding
radionuclide scan should be performed to locate the
bleeding site as well as to intervene therapeutically.
 Initially, Vasoconstrictive agents, such as vasopressin,
epinephrine, propranolol can be used.
 Vasoconstriction reduces the blood flow and facilitates
plug formation in the bleeding vessel.
 Although epinephrine and propranolol reduced
mesenteric blood flow, they also caused a rebound increase
in blood flow and recurrent bleeding.

68.  Vasopressin causes severe vasoconstriction in the
splanchnic bed. Vasopressin infusions are more effective in
diverticular bleeding, which is arterial, as opposed to
angiodysplastic bleeding, which is of the venocapillary
type.
 Intra-arterial vasopressin infusions begin at a rate of 0.2
U/min, with repeat angiography performed after 20
minutes. The bleeding stops in about 91% of patients
receiving intra-arterial vasopressin.
 If bleeding persists, the rate of the infusion is increased to
0.4-0.6 U/min. Once the bleeding is controlled, the
infusion is continued in an intensive care setting for 12-48
hours and then tapered over the next 24 hours.

69. Superselective Embolization:
 This therapeutic modality is useful in patients in whom
vasopressin is unsuccessful or contraindicated.
 Embolization involves superselective catheterization of the
bleeding vessel to minimize necrosis.
 Embolization with agents such as gelatin sponge, coil
springs, polyvinyl alcohol, and oxidized cellulose.
 It is performed using a 3 French (F) microcatheter placed
coaxially through the diagnostic 5F catheter.
 Once the bleeding vessel is identified, microcoils are used
to occlude the bleeding vessel.
 Although microcoils are most commonly used, polyvinyl
alcohol and Gelfoam are also used alone or in conjunction
with microcoils.

70. Complications: Colonic infarction, bowel wall injury, Intestinal
ischemia and infarction.
 To prevent this complication, perform embolization as
close as possible to the bleeding point in the terminal
arteries.

71. ENOSCOPIC THERAPY
 Endoscopic control of hemorrhage is suitable for GI polyps
and cancers, arteriovenous malformations, mucosal
lesions, postpolypectomy hemorrhage, endometriosis,
colonic and rectal varices.
 It can be achieved using thermal modalities or sclerosing
agents.
 Absolute alcohol, morrhuate sodium, and sodium
tetradecyl sulfate can be used for sclerotherapy of lower GI
lesions.
 Endoscopic epinephrine injection is used commonly
because of its low cost, easy accessibility, and low risk of
complications.

72. Surgery
 Emergent surgery is required in patients with (LGIB) if
non operative management is unsuccessful.
Indications of Surgery :
 Persistent hemodynamic instability with active
bleeding.
 Persistent, recurrent bleeding.
 Transfusion of more than 4 units packed red bloods
cells in a 24-hour, with active or recurrent bleeding.
 No contraindications exist with regard to surgery in
hemodynamically unstable patients with active
bleeding.

73. Segmental bowel resection and subtotal colectomy
 Segmental bowel resection following precise localization of
the bleeding point is a well-accepted surgical practice in
hemodynamically stable patients.
 Subtotal colectomy is the procedure of choice in patients
who are actively bleeding from an unknown source.
 Patients who are hemodynamically stable should have
preoperative localization of the bleeding; once it is
localized, intra-arterial vasopressin is used as a
temporizing measure to reduce the bleeding before
patients undergo segmental colectomy.
 If the it is not localized, a subtotal colectomy with
ileoproctostomy is performed.

74. Complications
 The most common early postoperative
complications are intra-abdominal bleeding,
mechanical bowel obstruction, intra-abdominal
sepsis, localized or generalized peritonitis, wound
infection and/or dehiscence.
 Intra-abdominal sepsis following colorectal
surgery is a life-threatening complication and
requires aggressive resuscitation.
 Systemic conditions (eg, severe blood loss and
shock, poor bowel preparation, diabetes,
malnutrition, hypoalbuminemia) may adversely
affect anastomotic healing.

75.  Changes in anatomy and physiology of the large
bowel, high bacterial content, improper operative
technique, and ischemia can cause anastomotic
leak associated with abscess and intra-abdominal
sepsis.
 Delayed complications usually occur more than 1
week after surgery, the most common of which are
anastomotic stricture, incisional hernia, and
incontinence.

76. Nursing management of GI
bleeding:
 Nursing assessment:

77. Nursing Diagnosis:
 Fluid volume deficit related to acute loss of blood, as
well as gastric secretions.
 Ineffective tissue perfusion related to loss of
circulatory volume
 Anxiety related to upper to upper GI
bleeding,hospitalization,source of bleeding.
 Decrease cardiac output related to blood loss.
 Risk for aspiration related to active blreeding

78. Impact of anticoagulation on
rebleedings:
 Anticoagulation should be stopped immediately.
 The prescence of mild to mod anticoagulation(INR 1.3-
2.7) did not appear to alter the outcomes of endoscopic
therapy.
 Patients who require an antiplatelet medication and
have a history of ulcer bleeding will have less chance of
recurrent bleeding if they take aspirin 81 mg and a PPI
daily compared with clopidogrel alone.

79. OTHER INTERVENTION
 Vitals are monitored
 Assessment of severity of blood loss :- An orthostatic decrease of 20
mm Hg in systolic blood pressure or increases in the pulse of 20
beats / min. indicate – 10% blood loss, if pt is pulsless and in shock-
> 20% loss.
 Order hemoglobin, hematocrit, BUN, grouping and cross matching
of blood.
 Insertion of central venous line may be beneficial to measure
adequacy of fluid replacement and perfusion of vital organ .
 Monitor urine output.
 Fluid resuscitation is done by crystalloids such as normal saline or
RL if hypoalbuminemia is detected use colloids.
 Placing the patient in trendelenburg position to maintaine cerebral
blood flow.

80. CONT…
 1.Oxygen support to prevent hypoxia of tissues
 2.IV route - Crystaloid solution/Colloids|blood.
 3. Blood transfusion:
 maintain Hct at 30% in the elderly, esp. with comorbid deseases
eg. CHF, CRF, IHD,COPD)
 20-25% in younger pt
 25-28% in portal HTN
 administration of vit k
 4.In symptomatic thrombocytopenia (<50000 )infused platelets.
 5.FFP-The transfusion of plasma should not be based solely on
the patient’s abnormal INR and/or PTT.


81. CONCLUSION

82. BIBLIOGRAPH
Y