This document discusses upper and lower gastrointestinal bleeding. It provides information on clinical presentations, patient assessment, resuscitation, differential diagnoses, endoscopic therapies, and key points. The main causes of upper GI bleeding are reported to be peptic ulcers and esophageal varices. Colonoscopy is the preferred initial evaluation for lower GI bleeding and can be both diagnostic and therapeutic.

1. Upper and lower
Gastrointestinal Bleeding

2. GI Bleeding
• Clinical Presentation
• Acute Upper GI Bleed
• Acute Lower GI Bleed

3. Clinical Presentation
Hematemesis: bloody vomitus (bright red or
coffee-grounds)
Melena: black, tarry, foul-smelling stool
Hematochezia: bright red or maroon blood
per rectum
Occult: positive guaiac test
Symptoms of anemia: angina, dyspnea, or
lightheadedness

4. Patient Assessment
• Hemodynamic status
• Localization of bleeding source
• CBC, PT, and T & C
• Risk factors
– Prior h/o PUD or bleeding
– Cirrhosis
– Coagulopathy
– ASA or NSAID’s

5. Resuscitation
• 2 large bore peripheral IV’s
• Normal saline or LR
• Packed RBCs
• Correct coagulopathy

6. Location of Bleeding
• Upper
– Proximal to Ligament of Treitz
– Melena (100-200 cc of blood)
– Azotemia
– Nasogatric aspirate
• Lower
– Distal to Ligament of Treitz
– Hematochezia

7. Acute UGIB
Demographics
• 10,000 - 20,000 deaths annually
• Mortality stable at 10%
• 80% self-limited
• Continued or recurrent bleeding -
mortality 30-40%

8. • Cause of bleeding
• Severity of initial bleed
• Age of the patient
• Comorbid conditions
• Onset of bleeding during
hospitalization
Acute UGIB
Prognostic Indicators

9. NASOGASTRIC
ASPIRATE
STOOL
COLOR
MORTALITY RATE
(%)
Clear Red, brown, or black 10
Coffee Grounds Brown or black 10
Red 20
Red Blood Black 10
Brown 20
Red 30
Acute UGIB
Prognostic Indicators
Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

10. Acute UGIB
Differential Diagnosis

11. • Peptic ulcer disease
– Gastric ulcer
– Duodenal ulcer
• Mallory-Weiss tear
• Portal hypertension
– Esophagogastric
varices
– Gastropathy
• Esophagitis
• Dieulafoy’s lesion
• Vascular anomalies
• Hemobilia
• Hemorrhagic
gastropathy
• Aortoenteric fistula
• Neoplasms
– Gastric cancer
– Kaposi’s sarcoma
Acute UGIB
Differential Diagnosis

12. DIAGNOSES % OF TOTAL
Duodenal ulcer 24
Gastric erosions 23
Gastric ulcer 21
Varices 10
Mallory-Weiss tear 7
Esophagitis 6
Acute UGIB
Final Diagnoses of the Cause in 2225 Patients
Tedesco et al. ASGE Bleeding Survey. Gastro Endo. 1981.

13. DIAGNOSES % OF TOTAL
Peptic ulcer 55
Varices 14
Angioma 6
Mallory-Weiss tear 5
Erosions 4
Tumor 4
Acute UGIB
Causes in CURE Hemostasis Studies (n=948)
Savides et al. Endoscopy 1996;28:244-8.

14. Acute UGIB
CORI Database
University, VA, & private
practices
20 months (12/99-7/01)
7822 EGDs for UGIB
BoonpongmaneeS. et al. Gastrointest Endosc 2004;59:788-94.

15. Endoscopic Appearance
of Ulcers

16. • Thermal
– Bipolar probe
– Monopolar probe
– Argon plasma
coagulator
– Heater probe
• Mechanical
– Hemoclips
– Band ligation
• Injection
– Epinephrine
– Alcohol
– Ethanolamine
– Polidocal
Endoscopic Therapy of PUD

17. Endoscopic Therapy of PUD
Laine and Peterson New Eng J Med 1994;331:717-27.

18. Adjuvant Medical Therapy
of PUD
• Acid suppression (intragastric pH > 4)
– Histamine 2 Receptor Antagonists (H2RAs)
• Ranitidine (Zantac)
• Famotidine (Pepcid)
– Proton Pump Inhibitors (PPIs)
• Pantoprazole (Protonix)
• Lansoprazole (Prevacid)
• Esomeprazole (Nexium)

19. Mallory-Weiss Tear

20. Esophageal Varices

21. Variceal Band Ligation

22. Variceal Band Ligation

23. • Vasopressin/Glypressin
• Nonselective vasoconstrictor
• 50% efficacy in controlling bleeding
• 25% vasospastic side effects
• Octreotide
• Cyclic octapeptide analog of
somatostatin
• Longer acting than somatostatin
• Equivalent to sclerotherapy and
improves endoscopic results
MEDICAL THERAPY
Acute Variceal Bleeding

24. TIPS
IVC
Portal Vein
Splenic Vein
Coronary Vein

25. Aortoduodenal Fistula
Aorta
Duodenum
Graft
Fistula

26. Acute UGIB
Surgery
• Recurrent bleeding despite
endoscopic therapy
• > 6-8 units pRBCs

27. Case Presentation
• CC: Hematochezia
• HPI: 74 yo woman presents with 6 hour
history of painless maroon blood per rectum
• PMHx: CAD, Chol, AFib, CABG, L-CEA
• Meds: ASA, coumadin, digoxin, lovastatin
• Vitals: BP 105/75 P 90
• PE: irreg rhythm, maroon blood on DRE

28. Acute LGIB
Differential Diagnosis

29. • Diverticulosis
• Colitis
– IBD (UC>>CD)
– Ischemia
– Infection
• Vascular anomalies
• Neoplasia
• Anorectal
– Hemorrhoids
– Fissure
• Dieulafoy’s lesion
• Varices
– Small bowel
– Rectal
• Aortoenteric fistula
• Kaposi’s sarcoma
• UPPER GI BLEED
Acute LGIB
Differential Diagnosis

30. DIAGNOSES % OF TOTAL
Diverticulosis 40
Vascular anomalies 30
Colitis 21
Neoplasia 14
Anorectal 10
Upper GI sites 10
Acute LGIB
Diagnoses in pts with hemodynamic compromise.
Zuccaro. ASGE Clinical Update. 1999.

31. Diverticulosis

32. Diverticular Bleeding

33. Hemorrhoids

34. Bleeding AVM

35. Radiation Proctitis

36. • Incidence 0.3 - 3.0 %
• Etiology Incomplete obliteration of
the vitelline duct.
• Pathology 50% ileal, 50% gastric,
pancreatic, colonic mucosa
• Complications
– Painless bleeding (children, currant jelly)
– Intussusception
Acute LGIB
Meckel’s Diverticulum

37. Study
Yield
%
Comments
Colonoscopy 69-80 Therapeutic
Arteriography 40-78
1 ml/min,
risks
Tagged RBC Scan 20-72 Localization
Acute LGIB
Evaluation
Zuccaro. ASGE Clinical Update. 1999.

38. • Resuscitation
• UGI source
• Most bleeding ceases
• Colonscopy - early
• No role for barium studies
• 5% Mortality
Acute LGIB
Key Points