GIT bleeding medical Emergency

1. GIT Bleeding
Prepared by:
Zana Hossam

2. Learning objectives
• To realize the importance of GI bleeding in clinical practice
• To define the different manifestations of GIB
• To identify the causes of GIB
• To be able to risk stratify cases of GIB
• To be able to manage cases of GIB

3. GIT bleeding
• GI bleeding is the most common gastrointestinal emergency
• Sites:
– 50% of admissions for GI bleeding are for upper GIB (UGIB; from
esophagus, stomach, duodenum).
– 40% are for lower GI (LGIB; from the colon and anorectum).
– 10% are for obscure bleeding.

4. Classified into:
– Upper GI bleeding (proximal ligament of Treitz)
– Lower GI bleeding (distal to ligament of Treitz)
• Upper GI bleeding 4x more common than lower GI
bleeding and is a major cause of morbidity and mortality.
GI Bleeding

6. Upper GIT Bleeding

7. Upper GIT Bleeding
• Upper gastrointestinal bleeding is defined as bleeding derived
from a source proximal to the ligament of Treitz.
• Upper GI bleed remains a major medical problem.
• About 75% of patient presenting to the emergency room with
GI bleeding have an upper source.
• Bleeding is self-limited in 80% of patients with UGI
hemorrhage, even without specific therapy.
• In-hospital mortality of 5-10% can be expected.

8. Causes of Upper GIT Bleeding

9. Clinical presentation
• Haematemesis
• Melaena
• Hematochezia
• Haematemesis without melaena
• Melaena without haematomesis
• Epigastric pain or diffuse abdominal pain
• Weakness ,Dizziness , Syncope or Presyncope .
• Dyspepsia
• Dysphagia
• Jaundice
• Weight loss

10. Clinical presentation
History
Important information to obtain includes potential comorbid
conditions, medication history, and potential toxic exposures, as well
as the severity, timing, duration, and volume of the bleeding.
Physical Examination
The goal of the patient's physical examination is to evaluate for
shock and blood loss & assessing the patient for hemodynamic
instability and clinical signs of poor perfusion

11. Severe GIT Bleeding
Is defined as GIT bleeding accompanied by shock or
orthostatic hypotension & a decrease in the hematocrit
value by at least 6% or a decrease in Hb of at least 2 g/dL
or transfusion of at least two units of packed RBC.

12. Risk Stratification
• Risk scoring systems have been developed to stratify risk
of mortality, rebleeding or need for endoscopic therapy .
• In general, all these scoring systems are better at
determining mortality than rebleeding.
• Blatchford Score
• Rockall Scoring System

13. 13

14. Variable Score 0 Score 1 Score 2 Score 3 Score
Calculate on admission
Age < 60 60-79 > 80
Shock No shock Pulse > 100 , SBP >100 SBP < 100
Comorbidity Nil major CHF, IHD, major comorbidity Renal/liver
failure
Metastatic cancer
Calculate after endoscopy
Diagnosis Mallory-Weiss tear or
normal
All other diagnoses GI malignancy1
Evidence of
bleeding
None Blood in stomach Adherent clot
Visible or
spurting vessel
Rockall score Final score (range 0-11)

15. Management
1. start by protecting the airway and giving high-flow O2
2. Intravenous access
Insert at least one large-bore cannula (14- or 16-gauge). Two if ongoing bleeding
3. Initial clinical assessment by history & physical examination.

16. Management cont…
3. Basic investigations
– Full blood count.
– Urea & Electrolyte
– Liver function tests
– Prothrombin time & INR
– Cross-matching
4. Prepare blood (2-8 units of packed RBC according to the
severity of bleeding).

17. Management cont…
5. Resuscitation
– Give 1-2 liters of normal saline as fast as possible to keep SBP > 100
mmHg and PR <100 BPM.
– Give packed RBC if the patient remains unstable after 2 L of crystalloids.
Also give packed RBC to keep Hb 7-9 g/dl (> 9 g/dl if acute coronary
syndrome or Child Pugh class-C cirrhosis or symptoms attributable to
anemia).
– Transfuse platelets & fresh frozen plasma to keep platelet > 50,000/mm3
& PT < 15 Sec, respectively
– Comorbidities should be managed as appropriate.
– Consult surgeon in cases of massive bleeding that cannot be medically
resuscitated.

18. 6. Monitoring
• Patients should be closely observed, with hourly
measurements of pulse, blood pressure
• Insert a urinary catheter and monitor hourly urine output
• CVP monitoring is useful in sever bleeding particularly in
patient with cardiac disease and to guide fluid
replacement & identification of rebleeding

19. Management cont…
7. Endoscopy
– It should be done after adequate resuscitation, ideally within 24
hours, and will yield a diagnosis in 80% of cases.
– Patients with major endoscopic stigmata of haemorrhage can
be treated endoscopically using a thermal or mechanical
modality, combined with adrenaline injection (Dual therapy).
– This may stop active bleeding and combined with intravenous
proton pump inhibitor (PPI) therapy (infusion for 72 hours),
prevent rebleeding, thus avoiding the need for surgery
(mortality is not reduced significantly).

20. 8. Surgery
– Surgery is indicated when endoscopic hemostasis fails to stop
active bleeding and if rebleeding occurs on one occasion in an
elderly or frail patient, or twice in a younger, fitter patient.
– If available, angiographic embolization is an effective
alternative to surgery in frail patients.

21. Management cont…
9. Prevention of recurrent ulcer bleeding:
– All patients should be tested for H. pylori and treated with H. pylori
eradication therapy if they test positive,
– Successful eradication should be confirmed by urea breath or faecal
antigen testing
– They should avoid NSAIDs.
– Repeated OGD in gastric ulcer after 6-10 weeks of PPI to confirm
healing & exclude malignancy

24. Post-care
1. In patients who underwent endoscopic therapy: absolute
bed rest for 24 hours, start oral intake after 6 hours.
2. Monitor for features of rebleeding
3. Consult endoscopist for rebleeding.
4. Test for H. pylori and eradicate if positive testing. Confirm
eradication.
5. Revise NSAID use.
6. Give long term maintenance acid suppression for 2-5
years in high risk patients.

25. Use of IV PPI
• Intravenous PPI given to patients subjected to endoscopic
therapy for major peptic ulcer hemorrhage reduce rebleeding
and need for surgery, but not mortality.
• When PPI are given prior to endoscopy, they reduce the need
for endoscopic therapy and hospital stay, but not the need for
surgery or mortality.

26. Lower GITBleeding

27. • Lower GI bleed refers to bleeding arising distal to the
ligament of Treitz
• Although this includes jejunum and ileum but bleeding
from these sites is rare (<5%)
• Vast majority of lower GI bleeding arises from
colon/rectum/anus
Lower GI bleeding

28. Causes of lower gastrointestinal bleeding
Severe acute
• Diverticular disease
• Angiodysplasia
• Ischaemia
• Meckel's diverticulum
• Inflammatory bowel disease
Moderate, chronic/subacute
• Anal disease e.g. fissure,
haemorrhoids
• Inflammatory bowel disease
• Carcinoma
• Large polyps
• Angiodysplasia
• Radiation enteritis
• Solitary rectal ulcer

29. Signs and symptoms
• The clinical presentation of Lower GIT Bleeding varies with
the anatomical source of the bleeding, as follows:
• Maroon stools, with LGIB from the right side of the colon
• Bright red blood per rectum with LGIB from the left side of the
colon
• Melena with cecal bleeding
• In practice, however, patients with upper GI bleeding and
right-sided colonic bleeding may also present with bright red
blood per rectum if the bleeding is brisk and massive.

30. Obscure GIT Bleeding
• Obscure is commonly defined as GIB of uncertain cause after a non-
diagnostic upper endoscopy, colonoscopy, and small bowel barium
follow through.
• Overt obscure GIB: patient has visible GIB (e.g., melena, maroon stool,
hematochezia)
• Occult obscure GIB patients has positive fecal occult blood test (FOBT)
or unexplained iron deficiency anemia (IDA).

31. Major GIB of unknown cause
• In some patients with major GIB, upper endoscopy and colonoscopy
fail to reveal a diagnosis.
1.When severe life-threatening bleeding continues, urgent CT mesenteric
angiography is indicated.
2.If angiography is negative or bleeding is less severe, push or double
balloon enteroscopy can visualize the small intestine and treat the
bleeding source.
3. Wireless capsule endoscopy is often used to define a source of
bleeding prior to enteroscopy.
4.When all else fails, laparotomy with on-table endoscopy is indicated.

32. Chronic occult GIT Bleeding
• Occult means that blood or its breakdown products are present in the
stool but cannot be seen by the naked eye.
• Occult bleeding may reach 200 mL per day and cause iron deficiency
anemia.
• Any cause of GIB may be responsible but the most important is
colorectal cancer, particularly carcinoma of the caecum, which may
produce no gastrointestinal symptoms.
• Many colorectal cancer patients are FOBT-negative at presentation,
and the only value of FOB testing is as a means of screening for
colonic disease in asymptomatic populations

34. Differentiation of UGIB from LGIB
1. Hematemesis indicates UGIB.
2. Melena indicates presence of blood in GIT for at least 14 h. It generally
indicates UGIB but Small Intestine or proximal colonic GIB.
3. Hematochezia indicates LGIB or brisk UGIB (hemodynamic instability).
4. Small bowel bleeding present with melena or hematochezia
5. Other clues to UGIB are hyperactive bowel sounds and an elevated blood
urea nitrogen
6. Non-bloody nasogastric aspirate occur in 18% of UGIB.
7. Even a bile-stained aspirate does not exclude a bleeding post-pyloric lesion
because reports of bile in the aspirate are incorrect in -50% of cases.
8. Testing of aspirates that are not grossly bloody for occult blood is not useful

35. References
• Davidson's Principles and Practice of Medicine 21st Ed
• GIT Bleeding PDF prepared By Dr. Ali A. Ramadhan
• www.medscape.com