This document discusses gastrointestinal bleeding (GIB), summarizing its main causes and approaches to management. It notes that upper GIB accounts for 80% of cases, with the most common causes being peptic ulcer disease, esophageal varices, esophagitis, and Mallory-Weiss tears. Lower GIB is more common in the elderly and can be caused by conditions like diverticulosis, colitis, ischemia, and hemorrhoids. Small intestinal bleeding is relatively uncommon but can now be identified in most patients using video capsule endoscopy, deep enteroscopy, or radiological imaging. The document provides guidance on assessing severity, differentiating upper from lower sources, initial resuscitation measures, the role of endoscopy,

1. Gastrointestinal bleeding(GIB)
Dr. Mohamed Alshekhani
Professor in Medicine/GEH
MBChB-CABM-FRCP-EBGH
2021

2. Introduction:
 • Upper :80%
 • Lower :15%
 • SIB:5%
 • Proximal or distal to the ligament of Treitz.

3. UGIB:
 • Presents with:
 • Hematemesis (bright-red or “coffee-ground” emesis)
 • Melena (black, tarry-appearing stool)
 • Or very rarely hematochezia or bright red blood per rectum due to
 briskly UGIB, which is associated with increased mortality.

4. UGIB : Causes
 • 80% is due to 4 causes:
 • PUD
 • EV
 • Esophagitis
 • Mallory-Weiss tear.
 • Bleeding in 80% stops spontaneously
 • 20% have persistent or recurrent bleeding, increasing mortality.

5. UGIB causes: slow & or chronic causes
 • Suggested by history of IDA.
 • Typical of erosive disease: tumor, esophageal ulcer, portal
 hypertensive gastropathy, Cameron lesion (5%, eroded large hiatal
 hernias)& angiodysplasia.

6. UGIB: causes
 Causes of brisk&/or severe upper GIB that increase mortality.
 • Peptic ulcer
 • Esophagogastric varices
 • Dieulafoy lesion
 • Aortoenteric fistula
 • Hemobilia: usually from liver or biliary procedural complication or
 gallstone complications, tumors &angiodysplasia.
 • Hemosuccus pancreaticus: (pseudoaneurysm/aneurysm)
 • Neoplasm
 • Esophageal lesions
 • Gastric GIST

7. UGIB: History
 H/O chronic alcohol abuse: a clue to the possibility of VH.
 • Chronic dyspepsia: PUD.
 • NSAIDs use: PUD.
 • H/O Aortic aneurysm repair: aortoenteric fistula.
 Predictors of severe GIB are:
 • Hematemesis
 • Comorbidities (such as cirrhosis or malignancy)
 • HD instability
 • Hb <8 g/dL (80 g/L).
 • bleeding source.

8. Management aims:
 Assessing severity.
 Differentiating upper from lower GIB sources.
 Determining the need for interventions.

9. Assessing severity:
 Outpatient management is usually appropriate when the following criteria
are met:
 • BUN<18.2 mg/dL (6.5 mmol/L)
 • Normal Hb
 • Systolic BP>109 mm Hg
 • PR< or equal to 100/min
 • Absence of: melena, Syncope,Liver disease,Cardiac failure.

10. Assessing severity:
 Risk-stratification tools guides decisions regarding:
 Hospital admission.
 Discharge home from ER.
 Urgent endoscopy (within 12 hours)
 Non-urgent endoscopy (within 24 hours)

11. Assessing severity:
 Severity scoring:
 Best validated &most useful is Glasgow-Blatchford score (0-23), of 9
 variables: BUN (0-6 points), Hb (0-6), SBP(0-3), PR(0-1), melena (0-
 1), syncope (0-2), hepatic disease (0-2 points)& HF(0-2).
 • Has a nearly 100% NPV for severe GIB& the need for hospital-based
intervention (blood transfusion, endoscopic therapy, TC arterial
embolization, surgery).
 UGIB is most reliably predicted by 4 variables: melena, NGT with blood or
“coffee grounds,” BUN/ Cr > 30 & absence of blood clots in the stool.

12. Management:
 1. Pre-endoscopic care (resuscitation, hemodynamic monitoring, PPI
 therapy, attention to coagulopathy)
 • 2. Early endoscopic evaluation (with excellent endoscopic vision) &
 treatment.
 • 3. Postendoscopic care & risk reduction.

13. Management: pre-endoscopic care
 1.Resuscitated with crystalloids to reach physiologic endpoints (PR
<100/min, SBP>100 mm Hg&resolution of orthostasis).
 • 2.Blood transfusion indicated:
 • A. HD instability &ongoing bleeding or susceptibility to complications
from hypoxia (for example IHD).
 • B. Target Hb < 7 g/dL, if HD stable with no active or massive bleeding.
 • 3.Early (pre-endoscopic) PPI does not improve clinical outcomes
(bleeding, surgery, mortality) but is safe & reduces the likelihood of
detecting ulcers with high-risk stigmata & need for endoscopic trt.
 • 4.Coagulopathy (INR >1.5) corrected with FRP not vit K (delayed full
therapeutic effect) in actively bleeding receiving anticoags.
 • 5.Octreotide & antibiotics should be given before endoscopy for
suspected variceal bleeding.

14. Management: pre-endoscopic care
 NGT is not required for diagnosis, prognosis, visualization, or therapeutic
effect.
 Beneficial for excluding UGI bleeding source before proceeding to lower
GIB management in HD unstable patients with Hematochesia.
 Routine use of prokinetics is not recommended except when patients are
suspected of having large amounts of blood in the UGIT; in such cases, IV
erythromycin can be given prior to upper endoscopy.

15. Management: endoscopic care
 Upper endoscopy within 24 hours of presentation in patients with features
of UGIB.
 Endoscopy within 12 hours is generally recommended only for patients
with suspected variceal bleeding.
 Low-risk ulcers not requiring endoscopic intervention are clean-based or
have a non-protuberant pigmented spot.
 Intermediate-risk ulcers have adherent clots can be left without
intervention or vigorously irrigated to dislodge the clot & reclassified
based on appearance.
 High-risk ulcers that require endoscopic treatment: active arterial
spurting or a non-bleeding visible vessel & visible vessel at ulcer base.
 Routine second-look endoscopy is not required after UGIB unless
rebleeding occurs or the initial examination was incomplete.

17. Management: post-endoscopic care
 Post endoscopic PPI improves outcome after endoscopic interventions.
 PUD tested for H pylori &If positive, eradication done &confirmed.
 If negative, re-testing done with an alternative method BZ of false-negative
results from bleeding, PPI, or concomitant antibiotics.
 Aspirin should be resumed within 3 - 5 days for patients with established
CVD.
 Long-term PPI may not be necessary for aspirin users who undergo H.
pylori testing &eradication.
 Long-term, daily PPI should be offered to aspirin users who are H. pylori
negative or those who use concomitant NSAIDs, anticoagulants,
glucocorticoids, or other antiplatelets.

18. Management: variceal bleeding
 10% of UGIB.
 Octreotide / telipresin infusion & antibiotics are given even if this is
suspected.
 FLuid resuscitation is preferred with crystaloids.
 Endoscopic intervention can be done safely even with INR up to 2.5 &
above that, correction done with FFP.
 Endoscopic band ligation is preferred over sclerotherpay for acute
esophageal variceal bleeding.
 Special eso stents used when above fail.
 For bleeding gastric varices cyanoacrylate sclerotherpay is preferred over
band ligation.
 When the above measures fail, temponade with esophgeal balloons as
Baltimore-Sengestaken tube is used as bridge to more definitive therapies
as TIPS or surgery.
 NS Beta-blockers are used after the control of the bleeding.

21. Lower GIB:
 Typically occurs in elderly.
 • Presents with hematochezia; acute bright red blood per rectum or red- or
maroon-colored stool.
 • HD instability is less common but, if present, raises the possibility of a
briskly bleeding UGI source.

22. Lower GIB:causes
 • Diverticulosis 30%
 • Colitis 24%
 • Ischemic 12%
 • IBD 9%
 • Radiation 3%
 • Hemorrhoids 14%
 • Postpolypectomy 8%
 • Colon polyps or cancer 6%
 • Rectal ulcer 6%
 • Angiodysplasia 3%
 • Other 6%.

23. Lower GIB: causes of severe type
• Diverticulosis
• Aortoenteric fistula
• Colonic or rectal varices
• Dieulafoy lesions
• Neoplasm
• Colitis
• Ischemic
• IBD
• Infectious
• Intussusception
• Meckel diverticulum
• Angiodysplasia

26. Small GIB:
 Relatively uncommon ; 5–10% of GIB.
 With advances in SI imaging(VCE, deep enteroscopy& radioimaging) the
cause of bleeding in SI identified in most patients.
 OGIB should be reserved for patients in whom a source of bleeding cannot
be identified anywhere in the GI tract.
 SIB should be considered in patients with GI bleeding after performance
of a normal upper & lower endoscopic exams.
 Second-look exams using upper endoscopy, push enteroscopy&/or
colonoscopy can be performed if indicated before SB evaluation.
 VCE should be considered a first-line procedure for SIB& should be
performed before deep enteroscopy if there is no contraindication.
 Any method of deep enteroscopy can be used when endoscopic
evaluation& therapy are required.

27. Small GIB:
 CTE should be performed in patients with suspected obstruction before
VCE or after negative VCE exams.
 When there is acute overt hemorrhage in the unstable patient,
angiography should be performed emergently.
 In patients with occult hemorrhage or stable patients with active overt
bleeding, multiphasic computed tomography should be performed after
VCE or CTE to identify the source of bleeding & guide further
management.
 If a source of bleeding is identified in the small bowel that is associated
with significant ongoing anemia and/or active bleeding, the patient should
be managed with endoscopic therapy.
 Conservative management is recommended for patients without a source
found after SB investigation, whereas repeat diagnostic investigations are
recommended for patients with initial negative SB evaluations & ongoing
overt or occult bleeding.