GASTROINTESTINAL

BLEEDING
(UGIB&LGIB)

By Dr.Samuel
 Outline
•Define GI bleed
•Common presentations
•Initial assessment(Hx&P/E)
•Common causes of UGIb
•Common causes of LGIB
•Different diagnostic tests and therapeutic
options
UPPER GASTROINTESTINAL BLEEDING
• Definition: Bleeding originating proximal to the
ligament of Treitz (oesophagus, stomach,
duodenum)
• Hematemesis = vomiting blood
– This is diagnostic of upper GI bleeding
• Melena = passage of tarry or maroon stool
– Can be upper or lower (more commonly upper)
• Hematochezia = Bright red blood per rectum
– Usually characteristic of colonic hemorrhage
•Acute GI bleed
–< 3 days duration
–Hemodynamic instability
–Requires blood transfusion
•Overt vs occult
–Overt: visible blood (melena,
hematochezia, bright red blood per
rectum, coffee ground emesis)
–Occult: detected only on lab tests (ie stool
cards)
 GI Bleeding
Maybe classified into:
– Upper GI bleeding
–Variceal bleeding
–Non-variceal bleeding
– Lower GI bleeding
• Upper GI bleeding 4x more common than
lower GI bleeding
• Emergency resuscitation same for upper and
lower GI bleeds
 History & Physical
• History of prior ulcers, NSAID use, stress
• History of Helicobacter pylori & treatment
• Alcohol abuse
– Retching -> Mallory Weiss tear
– Alcoholic cirrhosis -> portal hypertension
and varices
• On Physical Exam, assess hydration
• Look for stigmata of cirrhosis & portal HTN
• VITAL SIGNS
• Including orthostatic vital signs
• General: Distress?
• HEENT: blood in oropharynx? Pale conjunctiva?
• Heart: tachycardic?
• Abdomen: Soft? Distended? Tenderness to palpation?
• RECTAL EXAM!
• Melenic? (NOT melanotic!) Bright red?
• Hemorrhoids?
• Masses?
 Differential Diagnosis
• Peptic Ulcer Disease (PUD) >50% cases
• Gastritis / Duodenitis (15-30%)
– Subset due to NSAID use
• Varices from portal hypertension (10-20%)
• Mallory-Weiss tears at GE junction (5%)
• Esophagitis (3-5%)
• Malignancy (3%)
• Dieulafoy’s lesion (1-3%)
• Nasopharyngeal bleed – swallowed blood
• Other- Aortoenteric fistula, angiodysplasia, Crohn’s,
hemobilia, hemosuccus pancreaticus
Peptic ulcer. Peptic ulceration is the commonest
cause of upper GIB with DU bleeding four times
more common than GU which correlates to higher
incidence of duodenal ulcer.
There are four major risk factors for
bleeding peptic ulcers
• Helicobacter pylori infection
• Nonsteroidal anti-inflammatory drugs
(NSAIDs)
• Physiologic stress
• Excess gastric acid
Reduction or elimination of these risk
factors reduces ulcer recurrence and
rebleeding rates
Varices.
Bleeding from esophageal or gastric varices is
another common cause of UGIB in patients
with cirrhosis and portal hypertension
Gastritis. Acute gastritis (acute mucosal
erosions) causes frequent and possibly
massive bleeding and is usually associated
with ingestion of substances such as NSAID,
alcohol, corticosteroids, anticoagulants etc.
 Gastric Neoplasms.
Carcinoma of the stomach is the commonest
neoplastic cause of bleeding. Other less
common neoplasms include: Adenoma,
Angioma, and Lymphoma etc.
Stress ulcer- refers to acute gastro duodenal
lesions that arise in association with
(risk factors): Multiple system trauma,
Hypotension/shock, sepsis, Major burns, etc.
• Mallory-Weiss tears are longitudinal mucosal
tears extending across the esophagogastric
junction and follow prolonged violent
vomiting, often after a binge of alcohol.
Bleeding may be profuse, but in over 90 % of
cases, it stops spontaneously without specific
therapy and responds to conservative
measures such as sedation and volume
replacement.
• It is a longitudinal tear below the gastro-
oesophageal junction,which is induced by
repetitive and strenuous vomiting
Mallory–Weiss tear cont….
Mallory-Weiss tears are usually secondary to a
sudden increase in intraabdominal pressure.
Precipitating factors include
• vomiting,
• straining at stool or lifting,
• coughing,
• epileptic convulsions,
• hiccups under anesthesia,
• blunt abdominal injury,
 Management
Resuscitation
For patients in need of immediate resuscitation
and hospitalization:
Insert large bore IV cannula (preferably two)
• Restoration of blood volume is the initial
priority which is started with rapid crystalloid
infusion until blood is available (refer to the
treatment of shock)
• Blood is taken at this time for necessary
investigations including CBC BG& cross
matching, blood chemistry, etc.
Monitor response to resuscitation
measures with:
• Clinical monitoring (frequent evaluation),
e.g. vital signs, urine output, etc.
• Alleviate anxiety and pain, e.g. diazepam,
analgesics
• Once the patient is stabilized review
pertinent laboratory data and decide on
further treatment in conjunction with
the clinical setup of the patient
• e.g. need for transfusion
• Monitoring needs to be continued for
at least 3 days.
• Once again, make sure pt is resuscitated
• If anemic and symptomatic, give blood
• Place NGT/lavage (helps for endoscopy)
• Perform Upper endoscopy (EGD)
– For ulcers: if visible clot, visible vessel, or active
bleeding, should cauterize/coagulate and inject
sclerosing agent
– For acute variceal bleeding: sclerotherapy +
somatostatin or endoscopic band ligation. If
fail/rebleed: TIPS vs surgical shunt. Balloon
tamponade is an emergency temporizing measure
• Start proton pump inhibitor (PPI) infusion
 Risk stratification
The most important predictors of re-bleeding
are:
• Age > 80yrs
• Hb < 8g/dl
• Endoscopic stigmata of significant
hemorrhage (SSH)
• Co-morbidities
* These are combined in the risk stratification
score
 LOWER GI BLEEDING  
LGIB refers to blood loss of recent onset
originating from a site distal to the ligament of
Treitz .
Lower gastrointestinal bleeding (LGIB) can be:
- Small intestinal bleeding
- Colorectal bleeding
- Anorectal bleeding
• Small intestinal bleeding:
• Is uncommon, rarely is massive,
difficult to diagnose and usually a
diagnosis of exclusion after other
sources of bleeding have been ruled
out.
• Colonic bleeding: Can be acute and massive
or chronic presenting with occult blood
positive stool and anemia.
The causes include:
• Neoplasms and polyps
• Diverticulosis/ diverticulitis
• Vascular malformations
• Inflammatory causes e.g. intestinal
tuberculosis, inflammatory bowel diseases
Anorectal bleeding:
Causes include:
- Hemorrhoids
- Anal fissure
- Tumors /polyps
- Proctitis
• Diverticulosis  — A diverticulum is a sac-like
protrusion of the colonic wall. Its prevalenc is age-
dependent, increasing from less than 20 % age 40 to
60 % by age 60
• Angiodysplasia  — is dilated, tortuous submucosal
vessels. The walls of these vessels are composed of
endothelial cells that lack smooth muscle.
• Angiodysplasia appears endoscopically as
peripherally expanding dilated capillaries with a
central origin typically measuring between 0.1 and
1.0 cm in
• LGI angiodysplasia is uncommon in the general
population
 PPROACH TO THE PATIENT 
 A patient with LGIB typically complains of
hematochezia (passage of maroon or bright red
blood or blood clots per rectum).
 Blood originating from the left colon tends to be
bright red in color, whereas bleeding from the right
side of the colon usually appears dark or maroon-
colored and may be mixed with stool.
 This is different from the clinical presentation of
UBIB, which includes hematemesis (vomiting of
blood- or coffee ground-like material and melena
(black, tarry stools).
A NGT lavage that yields blood- or coffee
ground-like material confirms UBIB however,
lavage may not be positive if bleeding has
ceased or arises beyond a closed pylorus.
The presence of bilious fluid suggests that
the pylorus is open and, if lavage is negative,
that there is no active upper GI bleeding
proximal to the ligament of Treitz.
Visible rectal bleeding occurring in adults
warrants an evaluation in all
• Patients with LGIB can be categorized
into either low- or high-risk.
High-risk features include:
• Hemodynamic instability (hypotension,
tachycardia, orthostasis, syncope)
• Persistent bleeding
• Significant comorbid illnesses
• Advanced age
• Bleeding that occurs in a patient who is
hospitalized for another process
High-risk features cont…..
• A prior history of bleeding from diverticulosis
or angiodysplasia
• Current aspirin use
• A non-tender abdomen
• Anemia
• An elevated blood urea nitrogen level
• An abnormal white blood cell count
The number of high-risk features correlates with
the likelihood of poor outcome.
• Patients without high-risk findings require less
aggressive care .
 Physical examination:
• Vital signs and other indices of tissue
perfusion and signs of chronic blood loss
should be looked for.
• Do complete abdominal examination
including digital rectal examination, and
pelvic examination in female patients
• Treatment: Patients who are low risk (e.g. -
a young, otherwise healthy patient with self
limited rectal bleeding secondary to
hemorrhoid) may be evaluated as an
outpatient.
• Resuscitation: Resuscitation is the first
priority initiated while the patient is being
assessed and its progress should be
monitored closely (refer to the management
of hypovolemic shock).
• Diagnostic evaluation: With further clinical
assessment and investigations performed
after the patient is hemodynamically stable
Based on the patient's clinical setting and
availability investigations could be performed
which include:
- NG tube lavage to exclude UGIB
- CBC (WBC, HCT/Hb, platelet count…)
- Emergency esophago-gastro-duodenoscopy
(EGD) may be needed
Diagnostic evaluation cont….
- Blood chemistry
- Coagulation profile
- Stool examination for- parasites, blood
cells, Occult blood in chronic occult cases
- Lower GI Endoscopy: procto-
sigmoidoscopy: Valuable for visualization
biopsy taking and endoscopic treatment.
- Contrast studies- useful in chronic GI
bleeding
• Blood transfusions  — The decision to initiate
blood transfusions must be individualized.
• Our approach is to initiate blood transfusions if
the hemoglobin is <7 g/dL for patients who do
not have significant comorbid illnesses, with a
goal of maintaining the hemoglobin at a level
≥7 g/dL . However, our goal is to maintain the
hemoglobin at a level of ≥9 g/dL for patients at
increased risk of suffering adverse events in
the setting of significant anemia, such as those
with unstable coronary artery disease.
• Patients with active bleeding and hypovolemia
may require blood transfusion despite an
apparently normal hemoglobin.
• It is particularly important to avoid
overtransfusion in patients with suspected
variceal bleeding, as it can precipitate
worsening of the bleeding .
• Transfusing patients with suspected variceal
bleeding to a hemoglobin >10 g/dL should be
avoided
• Patients with active bleeding and a
coagulopathy (prolonged prothrombin time
with INR >1.5) or low platelet
count (<50,000/microL) should be transfused
with fresh frozen plasma (FFP) and platelets,
respectively.
• Provided the patient is hemodynamically
stable, urgent endoscopy can usually proceed
simultaneously with transfusion and should
not be postponed until the coagulopathy is
corrected.
THANK YOU!!