The document provides a comprehensive overview of upper and lower gastrointestinal bleeding, including definitions, causes, symptoms, diagnostic methods, and management strategies. It emphasizes the importance of endoscopy and laboratory tests in diagnosing and treating acute bleeding, as well as guidelines for fluid resuscitation and transfusion. Additionally, it discusses factors that contribute to rebleeding and the clinical implications of various bleeding sources.

1. Upper and Lower
Gastrointestinal
Bleeding
Internal medicine
Class.BMS.4.1
DR:Abdullahi hussein

2. Upper Gastrointestinal
Bleeding

3. Definition
Upper GI bleeding (UGIB) is defined as bleeding
derived from a source proximal to the ligament of
Treitz.
Acute gastrointestinal (GI) bleeding is a potentially
life-threatening abdominal emergency that remains
a common cause of hospitalization.

4. Epidemiology
The incidence of UGIB is approximately 100 cases
per 100,000 population per year.
Bleeding from the upper GI tract is approximately
4 times more common than bleeding from
the lower GI tract.
Is a major cause of morbidity and mortality.

5. Causes of Upper Gi Bleeding
Gastric and/or duodenal ulcers
Severe or erosive gastritis/duodenitis
Severe or erosive esophagitis
Esophagogastric varices
Portal hypertensive gastropathy
Angiodysplasia (also known as vascular ectasia)
Mallory-Weiss syndrome
Mass lesions (polyps/cancers)
Hemophila

6. • Bleeding manifestations
Hematemesis (either red blood or coffee-ground
emesis) suggests bleeding proximal to the ligament
ofTreitz.
The presence of frankly bloody emesis suggests
moderate to severe bleeding that may be ongoing,
whereas coffee-ground emesis suggests more
limited bleeding.

7. The majority of melena (black, tarry stool)
originates proximal to the ligament of Treitz.
Melena may be seen with variable degrees
of blood loss, being seen with as little as 50
mL of blood.
Hematochezia can occur with massive
upper GI bleeding.
Associated with orthostatic hypotension.

8. Symptom assessment
Patients should be asked about symptoms as part of
the assessment of the severity of the bleed.
As a part of the evaluation for potential bleeding
sources.
Symptoms that suggest the bleeding is severe include:
orthostatic dizziness.
Confusion.
Angina.
severe palpitations and cold/clammy extremities.

9. Specific causes of upper GI bleeding may be suggested by the
patient's symptoms:
 Peptic ulcer – Upper abdominal pain
 Esophageal ulcer – Odynophagia, gastroesophageal reflux,
dysphagia
 Mallory-Weiss tear – Emesis, retching, or coughing prior to
hematemesis
 Variceal hemorrhage or portal hypertensive gastropathy:
Jaundice, abdominal distention (ascites)
 Malignancy – Dysphagia, early satiety, involuntary weight
loss, cachexia

10. Physical examination
Mild to moderate hypovolemia – Resting
tachycardia.
Blood volume loss – Orthostatic hypotension
Blood volume loss of at least 40 percent – Supine
hypotension.
Abdominal pain with rebound tenderness or
involuntary guarding, raises concern for perforation.

11. Laboratory data
• Laboratory tests that should be obtained in
patients with acute upper gastrointestinal
bleeding include:
• Complete blood count.
• Serum chemistries.
• Liver tests.
• Coagulation studies.

12. Upper endoscopy:
Upper endoscopy is the diagnostic modality of
choice for acute upper GI bleeding
Endoscopy has a high sensitivity and specificity for
locating and identifying bleeding lesions in the upper
GI tract.
Early endoscopy (within 24 hours) is recommended
for most patients with acute upper GI bleeding.
For patients with suspected variceal bleeding, we
perform endoscopy within 12 hours of presentation.

19. It may be helpful to give a
prokinetic agent such as
erythromycin or to irrigate the
stomach prior to endoscopy
to help remove residual blood
and other gastric contents.

20. Other diagnostic tests for acute upper GI bleeding
include
Ct angiography (CTA), which can detect active
bleeding.
Deep small bowel enteroscopy.
Intraoperative enteroscopy.
A colonoscopy is generally required for patients
with hematochezia and a negative upper endoscopy

21. Factors associated with rebleeding identified in a
meta-analysis included:
Hemodynamic instability (systolic blood pressure
less than 100 mmHg, heart rate greater than 100
beats per minute)
Hemoglobin less than 10 g/L
Active bleeding at the time of endoscopy
Large ulcer size (greater than 1 to 3 cm in various
studies)
Ulcer location (posterior duodenal bulb or high
lesser gastric curvature)

22. GENERAL MANAGEMENT
Adequate peripheral access should be attained
with two 18 gauge.
Larger intravenous catheters.
Large-bore, single-lumen central cordis.
Patients should receive supplemental oxygen by
nasal cannula
initially should receive nothing per mouth in the
event urgent upper endoscopy is needed.

23. Fluid resuscitation
 Fluid resuscitation should begin immediately
should not be delayed pending transfer of the
patient to an intensive care unit.
Patients with active bleeding should receive
intravenous fluids (eg, 500 mL of normal saline or
lactated Ringer's solution over 30 minutes)

24. Transfusion
Patients with active bleeding and hypovolemia may
require red blood cell transfusion.
Particularly if the patient remains hemodynamically
unstable despite appropriate fluid resuscitation.
Should receive a blood transfusion if the
hemoglobin is <9 g/dL (90 g/L).

25. However, it is important to avoid overtransfusion
in patients with suspected variceal bleeding.
The blood transfusion goals for variceal bleeding
are to transfuse if the hemoglobin is <7 g/dL (70
g/L).
Transfusion can precipitate worsening of the
bleeding (Cerqueira,Andrade, Correia, Fernandes, & Manso, 2012).

26. Transfusion of platelets may be required if the platelet count
is <50,000/microL.
prothrombin complex concentrate is indicated if the INR is
>2.
Treatment with low dose vitamin K or fresh frozen plasma if
hemodynamically unstable.
Fresh frozen plasma and platelets after every four units of
blood.

27. Acid suppression
 give a high-dose bolus (eg, esomeprazole 80 mg)
a second dose of an IV PPI should be given 12
hours later (eg, esomeprazole 40 mg).
For patients who may have stopped bleeding (eg,
patients who are hemodynamically stable with
melena), we give an IV PPI every 12 hours (eg,
esomeprazole 40 mg).

28. Vasoactive medications
Somatostatin, its analog octreotide and terlipressin
are used in the treatment of variceal bleeding.
octreotide is given as an intravenous bolus of 50
mcg, followed by a continuous infusion at a rate of
50 mcg per hour.

29. THERAPEUTIC ROLE OF ENDOSCOPY
• Methods of endoscopic hemostasis for acute UGIB
and LGIB include:
• Injection (usually diluted epinephrine or a
special sclerosing agent).
• Contact and non-contact thermal devices
(unipolar or bipolar electrocoagulation, heater
probes, and argon plasma coagulation).
• Mechanical devices (endoscopic clips and band
ligation) (Jung & Moon, 2019).

30. Lower Gastrointestinal
bleeding

31. Definition
lower gastrointestinal bleeding was defined
as bleeding originating distal to the
ligament of Treitz.
 acute lower gastrointestinal bleeding is
defined as the onset of hematochezia
originating from either the colon or the
rectum.

32. Epidemiology
Lower gastrointestinal bleeding (LGIB) that
requires hospitalization represents less than 1% of
all hospital admissions in the United States.
Worldwide, acute LBIG accounts for 1%-2% of
hospital emergencies.
Colonic diverticular disease is the most common
cause of LGIB.
Hemorrhoids are the most common cause of LGIB
in patients younger than 50 years.

33. The causes of acute lower GI bleeding may
be grouped into several categories:
Anatomic (diverticulosis).
Vascular (angiodysplasia, ischemic,
radiation-induced).
Inflammatory (infectious, inflammatory
bowel disease).
Neoplastic.

35. Clinical Manifestations
A patient with lower gastrointestinal (GI) bleeding
typically reports hematochezia
Blood originating from the left colon tends to be
bright red in color,
Bleeding from the right side of the colon usually
appears dark or maroon colored.
Rarely, bleeding from the right side of the colon
will present with melena.

36. Patients should also be asked about symptoms that
may suggest a particular etiology for the bleeding.
Painless hematochezia with diverticular bleeding.
Change in bowel habits with malignancy.
Abdominal pain with colitis.

37. Patients should be asked about medication use,
Particularly agents that are associated with
bleeding or that may impair coagulation, such as.
 Nonsteroidal antiinflammatory agents,
 Anticoagulants, and
Antiplatelet agents.

38. Physical examination:Signs of hypovolemia include:
 Mild to moderate hypovolemia: Resting tachycardia
 Blood volume loss of at least 15 percent: Orthostatic
hypotension.
 Blood volume loss of at least 40 percent: Supine
hypotension
 The presence of abdominal pain suggests
the presence of an inflammatory bleeding
source such as ischemic or infectious colitis
or a perforation

39. Diagnosis
Colonoscopy is the initial examination of choice for
the diagnosis and treatment of acute lower GI
bleeding.
Computed tomographic (CT) angiography.
Mesenteric angiography.
These radiographic procedures require active
bleeding at the time of examination

40. Colonoscopy
Potential to precisely localize the site of the
bleeding
The ability to collect pathologic specimens, and the
potential for therapeutic intervention.
Disadvantages of colonoscopy include
the need for bowel preparation.
poor visualization in an unprepared or poorly prepared
colon.
the risks of sedation in an acutely bleeding patient.

41. Treatment of the bleeding site
In many cases, the bleeding can be controlled with
therapies applied at the time of colonoscopy or
angiography.
Rarely, patients with exsanguinating lower GI
bleeding will need immediate surgery.

42. Diverticular bleeding: Colonoscopy with bipolar
probe coagulation, epinephrine injection, or metallic
clips
Recurrent bleeding: Resection of the affected bowel
segment
Angiodysplasia:Thermal therapy (eg,
electrocoagulation, argon plasma coagulation)
Conservative management, including nothing by
mouth (NPO) and IV hydration in patients with
ischemic colitis

43. Indications for surgery include the following:
oActive persistent bleeding with hemodynamic
instability that is refractory to aggressive
resuscitation
oPersistent, recurrent bleeding
oTransfusion of more than 4 units of packed red
blood cells (PRBCs) in a 24-hour period, with active
or recurrent bleeding
oTransfusion of more than 6 units of PRBCs during
the same hospitalization

44. Recurrent lower Gi bleeding
A repeat colonoscopy should be performed with
endoscopic hemostasis if indicated
Factors associated with rebleeding include
the presence of underlying comorbidities,
antiplatelet/anticoagulant/NSAID use.
source of bleeding.
the initial modality of hemostasis.

45. •thank you
•END