Upper GI bleeding accounts for nearly 80% of significant gastrointestinal bleeding. Common causes of upper GI bleeding include peptic ulcer disease, esophageal varices, Mallory-Weiss syndrome, and erosive gastropathy. Lower GI bleeding accounts for about 20% and possible causes include diverticular disease, vascular abnormalities like angiodysplasia, inflammatory conditions, and neoplasms. Evaluation of a patient with GI bleeding involves assessing severity, identifying potential sources, and looking for conditions that may impact management. Initial evaluation includes history, physical exam, and lab tests. Endoscopy allows for diagnosis and potential treatment.

1. AMBO UNIVERSITY
COLLEGE MEDICINE AND HEALTH
SCIENCE
DEPARTMENT OF MEDICINE
SEMINAR PRESENTATION ON :-
GASTRO INTESTINAL BLEEDING
PREPARED BY: ABDISA GELETA
MODULATOR :DR SAMSON
2016 GC
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2. OUT LINE
• Introduction
• Ethiology of upper GI bleeding
• Ethiology of lower GI bleeding
• Approach to patient with GI bleeding
• Management course
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3. GI bleeding
• Gastrointestinal bleediing (GI bleeding), also
known as gastrointestinal hemorrhage, is all forms
of blood loss from the gastrointestinal tract.
• Bleeding is typically divided into two main
types: upper gastrointestinal bleeding and lower
gastrointestinal bleeding.
• Upper GI bleeding refers to bleeding that arises
from the GI tract proximal to the ligament of Treitz
and accounts for nearly 80% of significant blood
loss
• 20% LGIB- distal to ligament of Treitz
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4. Differentiation of UGIB and LGIB
4
•Hematemesis: vomiting bright red blood or blood that is
dark, like coffee grounds,Indicates upper GI bleeding
•Melena: passage of dark pitchy stools stained with blood
pigments Indicates upper GI bleeding
•Hematochezia: passage of bright red blood with stool.
Indicates lower GI bleeding
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5. • Hematochezia usually represents a lower GI
source of bleeding, although an upper GI
lesion may bleed so briskly that blood does
not remain in the bowel long enough for
melena to develop.
• When hematochezia is the presenting symptom
of UGIB, it is associated with hemodynamic
instability and dropping hemoglobin.
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6. possible cause upper GI bleeding
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7. Peptic ulcer disease
• Develop due to an imbalance between aggressive
factors and protective factors, leading to an
interruption in the mucosal integrity
• Aggressive factors .Protective factor
-acid -bicarbonate
-h.pylori -mucus
-pepsin - prostaglandin
-NSAID
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8. Types PUD
• Gastric ulcer:
– Burning, gnawing
epigastric pain that
occurs with anything in
the stomach;
– Pain is worst after eating
(in contrast to duodenal
ulcer).
– Anorexia/weight loss,
vomiting.
– Associated with blood
type A.
• Duodenal ulcer:
– Burning, gnawing
epigastric pain that occurs
with an empty stomach
(hunger pain) and is
relieved by food or
antacids (in contrast to
gastric ulcers).
– Night time awakening
(when stomach empties).
– Nausea, vomiting.
– Associated with blood type
O.
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9. 11/25/2017 9GI bleeding

10. Esophageal Varices
• The increased pressure in the esophageal plexus
produces dilated tortuous vessels called varices.
• Variceal rupture produces massive hemorrhage
into the lumen.
•present with hematemesis, melena, or
hematochezia
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11. Mallory–Weiss Syndrome
• is characterized by longitudinal mucosal lacerations
(intramural dissections) in the distal esophagus and
proximal stomach, which are usually associated with
forceful retching.
Common Alcoholic patient after binge drinking
-First :- vomit food and gastric contents
-Followed by :- forceful retching & bloody vomitus.
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12. Risk factor
• Retching,
• Alcoholism
• Increased intraabdominal pressure
symptom
• Epigastric pain,
• Thoracic substernal pain,
• Hematemesis
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14. Erosive Gastropathy
• Endoscopically visualized subepithelial
hemorrhages and erosions
• Gastritis are mucosal lesions due to inflammatory
condition and, thus, do not cause major bleeding.
• NSAID use, alcohol intake, and stress more
aggravate
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15. Esophagitis
• Esophageal inflammation secondary to repeated
exposure of the esophageal mucosa to the acidic
gastric secretions in gastroesophageal reflux disease
(GERD) leads to an inflammatory response, which
can result in chronic blood loss.
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16. UGI TUMORS
• Acute bleeding represents a late stage of disease
when the neoplasm outgrows its blood supply and
causes mucosal ulceration.
• Bleeding can result from diffuse mucosal ulceration
or from erosion into an underlying vessel.
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18. Lower GI bleeding
• Bleeding that originates from sources located distal
to the Ligament of Treitz.
• Accounts for 1% of acute hospital admissions each
year.
• Much less common reason for hospitalization, when
compared with upper GI hemorrhage.
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19. • GI bleeding that persists or recurs without a diagnosed
etiology after the initial routine work-up is known as
Obscure GI bleeding.
• Approximately 5% of pts will have obscure GIB.
• Obscure GIB is further categorized as either:-
• Obscure occult or
• Obscure overt bleeding
• Small intestinal bleeding usually is considered under
obscure causes of GI bleeding
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20. possible causes of lower
gastrointestinal bleeding (LGIB
• Anatomic (diverticulosis)
• Vascular (angiodysplasia, ischemic, radiation-
induced)
• Inflammatory (inflammatory bowel disease,
infectious)
• Neoplastic
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21. Diverticular disease
• Presence of symptomatic diverticula.
• Most are asymptomatic, but 3–5% will develop massive
bleeding.
• 99% of patients with these bleeding require four or fewer
units of blood before they stabilize.
• Bleeding resolves without intervention 80% of the time.
• Rebleeding occurs in 25–30% of pts after the first episode.
• If bleeding ceases spontaneously a second time, the
recurrence rate is as high as 50%. 2111/25/2017 GI bleeding

22. Vascular cause
Bowel ischemia
• Occlusion of the inferior mesenteric artery can present
with abdominal colic and rectal bleeding.
• Risk groups are the elderly people who have evidence
of generalised atherosclerosis.
Angiodysplasia
• Angiodysplasia is a diseases of the elderly in which
vascular malformations develop in the proximal colon.
• Bleeding can be acute and profuse; it usually stops
spontaneously but commonly recurs. 2211/25/2017 GI bleeding

23. Inflammatory cuases
Infectious
• Bacterial (C. difficile , enterotoxic E. coli, Campylobacter
jejuni…),
• Viral (herpes simplex viruses, HIV, and CMV).
• Parasites (Amebiasis, Cryptosporidiosis, )
• Fungal (Candida species, Histoplasmosis)
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24. Noninfectious
• IBD:- UC, CD,
 GI bleeding may be the 1st presentation
 Bloody diarrhea (more in ulcerative colitis)
 acute hemorrhage (more likely in cd)
• Radiation colitis:
 After treatment for pelvic malignancies.
 Patients present with bright-red blood per rectum,
diarrhea, tenesmus, and crampy pelvic pain
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25. Neoplasia
• Colorectal carcinoma:
Not common but has to be ruled out in painless,
intermittent, and slow bleeding.
Frequently associated with iron deficiency anemia
• Polyps :-
more commonly, the bleeding occurs after a
polypectomy.
juvenile polyps are the second most common cause of
bleeding in patients younger than 20 years of age
• Others: lipoma, lymphoma, leiomyoma,
leiomyosarcoma
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26. Anorectal disease
• Haemorrhoids
• Anal fissures
• Anal fistula
• Proctitis: Actinomycosis israelii ,Treponema pallidum
• Rectal trauma
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27. Haemorrhoids and anal fissures
Dilated veins both from deep and superficial plexus
• Haemorrhoidal bleeding is bright red and occurs
during or after defecation.
• Types-internal and external
Anal fissure should be suspected when fresh rectal
bleeding and anal pain occur during defecation
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28. APPROACH TO THE PATIENT
GI BLEEDING
Goal of the evaluation:
• To assess the severity of the bleed,
• Identify potential sources of the bleed &
determine if there are conditions that may affect
subsequent management.
Initial evaluation
• Includes a history, physical examination& laboratory
tests
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29. History
• Abdominal pain
• Hematemesis
• Melana
• Hematochezia
• Features of blood loss: shock, anemia
• Features of underlying cause: dyspepsia, jaundice,
weight loss
• Drug history: - like
NSAIDs(Aspirin)
Anticoagulants,
•History of epistaxis or hemoptysis
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30. Bleeding manifestations:
• Hematemesis (red blood or coffee-ground emesis)-
UGIB
-frankly bloody emesis -moderate to severe bleeding
that may be ongoing,
-coffee-ground emesis-limited bleeding.
• melena (black, tarry stool)- UGIB(90%)
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31. • Hematochezia :- LGIB or if it is massive
UGIB(orthostatic hypotension)
-bright red:-left colon
-Maroon colour:-right side of colon
-Hematochezia with abdominal pain;may represent
ischemic colitis,
-Painless hematochezia:- diverticulosis and colonic
tumors
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32. patients can be
• Low risk patients
Self limited bleeding, young and otherwise healthy
patients ;Internal hemorrhoid
• High risk patients
hemodynamic instability, serious comorbid diseases,
persistent bleeding-promptly resuscitate and
hospitalize and need more evaluation
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33. Symptom assessment:
To assess the severity and potential source of bleeding,
orthostatic dizziness, confusion, angina, severe
palpitations, and cold extremities-severe bleeding
Epigastric or right upper quadrant pain
Odynophagia, dysphagia
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34. Emesis, retching, or coughing prior to hematemesis
Jaundice, weakness, fatigue, anorexia, abdominal
distention
 Dysphagia, early satiety, involuntary weight loss,
cachexia
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35. • Medication History
 Pay attention to:
aspirin and other NSAIDs
antiplatelet agents and anticoagulants
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36. • Assess comorbid illnesses
 illnesses may:
-Make patients more susceptible to hypoxemia eg CAD,
pulmonary disease
-Predispose patients to volume overload eg CHF, renal
disease ;need attention during resustation
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37. -Result in bleeding that is more difficult to control (eg,
coagulopathies, thrombocytopenia, significant hepatic
dysfunction)-may need fresh frozen plasma or
platelets.
-Predispose to aspiration (eg hepatic encephalopathy)—
needs intubation.
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38. Distinguishing upper vs lower
• upper GI bleeding
– History
• Previous NSAID use
• Previous PUD
• Alcoholism
• Previous stomach surgery
• Retching/vomiting
• Weight loss
• Medications such as anticoagulants, antiplatelets
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39. – Symptoms
• Nausea/vomiting
• Hematemesis
• Melena
• Rarely hematochezia (massive bleed)
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40. 11/25/2017 GI bleeding 40
• Lower GI bleeding
-History
• Previous colon cancer
• Previous colon surgery
• Known diverticulosis
• Known hemorrhoids

41. – Symptoms
• Abdominal pain or can be painless
• Hematochezia
• Melena
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42. Physical examination
• Signs of hypovolemia
Resting tachycardia- Mild to moderate
hypovolemia
Orthostatic hypotension-at least 15% blood loss
 Supine hypotension-at least 40% loss
• SKIN changes:
– Palmar erythema-Cirrhosis
– Purpura /Echymosis-Bleeding disorders
• Signs of dehydration (dry mucosa, sunken eyes)
• Digital rectal exam: fresh blood, occult blood may be
found.
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43. Estimating Degree of Blood Loss RR, HR, and BP can be used
to estimate the degree of blood loss/hypovolumia
Class I Class II Class III Class IV
Volume Loss (ml)
Or %
0-750 or
Up to 15%
750-1500 or
15-30%
1500-2000 or
30-40%
>2000 or
>40%
RR 14-20 20-30 30-40 >40
HR <100 >100 >120 >140
BP unchanged unchanged reduced reduced
Urine Output
(ml/hr)
>30 20-30 5-15 Anuric
Mental State Restless Anxious Anxious/confuse
d
Confused/
lethargic
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44. Lab Diagnosis
• CBC, blood group
-(CBC, WBC, HCT/Hb, platelet count…)
-Hb may be normal initially
-CBC should be checked frequently(q4-6h) during
the first day.
-Patients with slow, chronic GIB may have very low
hemoglobin values despite normal blood pressure
and heart rate.
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45. • Blood chemistry
-BUN/creatinine >20:1 UGIB
• NG tube lavage to exclude UGIB
• LFT
• Coagulation studies
• ECG and cardiac enzymes
• Stool examination for- parasites, blood cells, Occult
blood in chronic occult blood loss
• GI Endoscopy, sigmoidoscopy: Valuable for
visualization biopsy taking and endoscopic treatment
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46. Nasogastric Lavage
• This procedure may confirm:-
-Recent bleeding (coffee ground appearance)
-Active bleeding (red blood in the aspirate)
-nonbloody bilious fluid-pylorus is open and that
there is no active upper GI bleeding distal to the
pylorus.
-Negative lavage-bleeding may be distal to closed
pylorus
-Lack of blood in the stomach (active bleeding
less likely but does not exclude an upper GI
lesion11/25/2017 GI bleeding 46

47. GI bleeding 47
to remove particulate matter, fresh blood, and
clots from the stomach to facilitate endoscopy.
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48. Endoscopy
• Initial diagnostic examination for all patients
presumed to have UGIB.
• Endoscopy should be performed immediately
after:-
-Endotracheal intubation (if indicated)
-Hemodynamic stabilization, and
-Adequate monitoring in ICU is achieved
• Used: Diagnostic and Therapeutic(Hemostasis,
luminal restoration (dilation, ablation, stenting),
lesion removal (e.g., polypectomy), percutaneous
endoscopic gastrostomy)
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49. Endoscopy cont…
• Urgent indication
-Shock
-Hct < 30
-Suspected variceal hemorrhage
-Recurrence of bleeding from unknown source
• Contra indication:- acute MI, , agitation,
circulatory imbalance
• Complication: aspiration, worsening of bleeding,
perforation,
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50. Endoscopy cont..
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51. Colonoscopy
-The gold standard for diagnosis of colonic mucosal disease
-Done for pts who don’t respond for resuscitation
-Gives good diagnosis yield if it is done with in 6-12hrs of
bleeding---Identifies lesion in 75 % or more
-Bowel preparation with purgatives 2-4hrs before the
procedure
-Can provide endoscopic therapy
-Complications 0.5-1 %
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52. Imaging
• Chest X-Ray-Chest radiographs should be ordered to
exclude aspiration pneumonia and effusion.
• Abdominal X-Ray- upright and supine films should be
ordered to exclude perforated viscus and ileus.
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53. Suggested algorithm for patients
with acute UGI bleeding
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54. Suggested algorithm for patients with
acute lower GI bleeding
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55. Management of GI bleeding
There are steps in GI bleeding Mgt
• Initial assessment
• Resuscitation measures
• Identifying source of bleeding
• Institution with specific therapy
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56. Management of GI bleeding
Patient Assessment
If the patient:
• Hemodynamically stable OPD
• No evidence of active bleeding
or
If the patient:
• Is hemodynamically unstable
• Is continuously bleeding ICU
• Hct drops by 6%
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57. Resuscitation
• Airways
Massive hematemesis +
mental obtundation
-Intubation
• Breathing
Administer oxygen with IN
cannula,or facemask or
endotracheal tube
• Circulation
-Fluid resuscitation
crystalloids (NS or RL)
• Blood transfusion
If Hb < 7 or actively
bleeding Hb goal =10
NB: cautions in high risk
patient
• Correct coagulopathy
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58. Specific Rx Measures- Upper GI
. Esophageal varices
-Endoscopy: Best therapy-band ligation & sclerotherapy
-Somatostatin, octereotide 50–100 µg/h IV infusion
-Vasopressin
-Propranolol
-Antibiotics
-Transjugular intrahepatic portosystemic shunt( TIPS)
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59. PUD
-PPI: pantoprazole 80mg iv bolus then 8mg/hr infusion,
if no bleeding in 24 hrs switch to PO Omeprazole
20mg/day
-Drugs enhancing mucosal defenses: prostaglandin
analogues (e.g misoprostol)
-Antacids –promote ulcer healing through stimulation
gastric defense mechanism
-Therapy of H.Pylori
(omeprazole20mg,amoxacillin1000mg,clarithromicin
500mg all po BID *10days)
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60. Surgical Mx GIB
UGIB:-indications are perforation, uncontolled
hemorrhage ,GOO and recurrent ulcer following gastric
surgery.
LGIB:-persitent or recurrent bleeding from wide variety
of colonic sources of GI bleeding that can not be
treated medically / endoscopically
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61. REFERENCES
-Harrison principles of internal medicine 18th edition.
-Up to date 21.6
-Cecil - Textbook of Medicine
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THANK YOU!