GI Bleeding

Gastroenterology
Gastrointestinal bleeds
With Kelley Chuang, M.D.
Led Joestar, pifeli2160@zevars.com

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Learning Objectives
In this lecture, you will learn to...
• distinguish between an upper and lower

GI bleed.
• categorize the severity of bleed based

on hemodynamic parameters.
• describe appropriate initial steps in

stabilization of a GI bleed.

56-year-old Man with Chronic Knee Pain Test case
Mr. Gibb is a 56-year-old man with chronic knee pain who

presents to the ED with 2 days of coffee ground emesis. He Concerning GI symptoms
complains of dull epigastric pain and nausea. He takes 800 mg
of ibuprofen 3 times a day for knee pain. He drinks 3 to 6 beers
a day. His only medications are a baby aspirin, metoprolol, and NSAID & alcohol use
ibuprofen.
Vitals: T 37.0°C (98.6°F), BP 89/55 mm Hg, HR 106/min, SpO2
98% on room air.
Physical exam reveals conjunctival pallor and tenderness to Signs of hypovolemia,
palpation in the epigastric region without rebound or guarding. anemia, and localizing
A nodular liver edge is palpated 5 cm below the costal margin. symptoms
His hemoglobin is 11 g/dL (prior 14 g/dL). Platelets are normal Hgb low (normal 14 18 g/dL
and his INR is 1.2. for adult male)
What is the best next step in management?

What Is the Difference Between an Upper and Lower GI Bleed?
Upper GI bleeds
present with melena
or hematemesis.
A brisk upper GI
bleed may sometimes Lower GI bleeds
also present with present with
hematochezia. hematochezia.
© by Lecturio
History: Important Risk Factors
Past medical history: prior GI bleeds, ulcers,

H. pylori, diverticulitis, hemorrhoids, IBD
Medications: NSAIDs, anticoagulants,

antiplatelet agents, iron supplements
Social history: smoking, heavy alcohol use
Comorbid conditions: cirrhosis, renal disease, cancer
Associated symptoms: dysphagia, weight loss,

preceding emesis, change in bowel habits

Differential Diagnosis
Upper GI bleed Lower GI bleed
Gastric or duodenal ulcers Diverticulosis
Erosive esophagitis, gastritis, duodenitis Hemorrhoids
Esophageal or gastric varices Inflammatory bowel disease
Portal hypertensive gastropathy Ischemic colitis
Arteriovenous malformations Arteriovenous malformations
Mallory-Weiss tear Infectious colitis
Malignancy Malignancy

Important Physical Exam Findings Diagnostic Tests
Physical exam Exam finding Significance

component
Resting tachycardia HR > 90/min Loss of < 15% total blood volume
Orthostatic Decrease in SBP 20 mm Hg Loss of > 15% total blood volume
hypotension or DBP 10 mm Hg from supine
to standing position
Supine Supine BP 90/60 mm Hg Loss of 40% total blood volume
hypotension
Abdominal exam Rebound, involuntary guarding, Peritoneal signs may indicate
extreme pain to palpation perforated viscus or bowel ischemia
Rectal exam Bloody or melanotic stool Check for anal fissure, hemorrhoids,
masses, and gross blood on stool
exam
Laboratory Studies
Complete blood count (CBC) for drop in Hgb or low platelet count
(initial Hgb may be normal due to delay in equilibration after blood loss)
Basic metabolic panel (BMP) for azotemia, or high

BUN:Cr ratio (elevated in upper GI bleed usually > 30:1)
Liver Panel (LFT) for low albumin
Coagulation factors (INR, PT, PTT) for coagulopathy
Elevated lactate (end organ dysfunction)

FOBT for GI Bleeds High Value Care Learning Point
A fecal occult blood test (FOBT) is not a screening tool for

active GI bleeding. It has a low sensitivity and specificity and
should only be used for colorectal cancer screening.

Best Steps in Initial Management
1 Establish adequate IV access:

2 large-bore (18 gauge or larger) peripheral IVs or centrally placed large-bore catheter
• Goal is to allow rapid infusion of blood products and fluids
• Recall from law that flow (Q) is affected by radius (r) and length (L)
∆𝑃𝜋𝒓4
𝑄=
8𝑛𝑳
Viscosity and Laminar Flow; Law, OpenStaxCollege, https://opentextbc.ca/physicstestbook2/chapter/viscosity-and-laminar-flow-

poiseuilles-law/, CC BY 4.0, no changes

∆𝑃𝜋𝑟 4
𝑄=
8𝑛𝐿
-
?
Shorter length and wider radius is associated with increased flow.
Viscosity and Laminar Flow; Law, OpenStaxCollege, https://opentextbc.ca/physicstestbook2/chapter/viscosity-and-laminar-flow-
poiseuilles-law/, CC BY 4.0, no changes


2 Fluid resuscitate ( solution)

3 Transfuse
• pRBC transfusion if Hgb < 7 g/dL
(Hgb < 8 g/dL for patients with unstable coronary artery disease or active bleeding)
• Platelet transfusion if plt < 50,000/µL

4 Give medications
• PPI
• Vasoactive medications (octreotide if variceal bleed)
• Reversal agents for anticoagulants if available

5 Consult GI specialist
Diagnostic (and Therapeutic) Studies
Gold standard Other options
• Upper endoscopy • Push enteroscopy
• Colonoscopy • Nuclear scintigraphy

(tagged RBC scan)
• CT angiography
• Standard angiography

56-year-old Man with Chronic Knee Pain Test case

complains of dull epigastric pain and nausea. He takes 800 mg  upper GI bleed
a day. His only medications are a baby aspirin, metoprolol, and NSAID & alcohol use  risk
ibuprofen. for peptic ulcer disease,
Vitals: T 37.0°C (98.6°F), BP 89/55 mm Hg, HR 106/min, SpO2 gastritis, malignancy
98% on room air.
What is the best next step in management?

56-year-old Man with Chronic Knee Pain Answer
Test case

complains of dull epigastric pain and nausea. He takes 800 mg  upper GI bleed
a day. His only medications are a baby aspirin, metoprolol, and NSAID & alcohol use  risk
ibuprofen. for peptic ulcer disease,
Vitals: T 37.0°C (98.6°F), BP 89/55 mm Hg, HR 106/min, SpO2 gastritis, malignancy
98% on room air.
Answer: establishing adequate IV access, aggressive fluid

resuscitation, PPI should be started.
Learning Outcomes
In this lecture, you have learned how to...
 distinguish between an upper and

lower GI bleed.
 categorize the severity of bleed

based on hemodynamic parameters.
 describe appropriate initial steps in

stabilization of a GI bleed.

This document is a property of: Led Joestar
Note: This document is copyright protected. It may not be copied, reproduced, used, or
distributed in any way without the written authorization of Lecturio GmbH.


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Gastroenterology

With Kelley Chuang, M.D.

Led Joestar, pifeli2160@zevars.com

In this lecture, you will learn to...

• distinguish between an upper and lower

• categorize the severity of bleed based

• describe appropriate initial steps in

Led Joestar, pifeli2160@zevars.com

Mr. Gibb is a 56-year-old man with chronic knee pain who

What is the best next step in management?

Led Joestar, pifeli2160@zevars.com

Past medical history: prior GI bleeds, ulcers,

Medications: NSAIDs, anticoagulants,

Social history: smoking, heavy alcohol use

Comorbid conditions: cirrhosis, renal disease, cancer

Associated symptoms: dysphagia, weight loss,

Led Joestar, pifeli2160@zevars.com

Upper GI bleed Lower GI bleed

Gastric or duodenal ulcers Diverticulosis

Erosive esophagitis, gastritis, duodenitis Hemorrhoids

Esophageal or gastric varices Inflammatory bowel disease

Portal hypertensive gastropathy Ischemic colitis

Arteriovenous malformations Arteriovenous malformations

Mallory-Weiss tear Infectious colitis

Led Joestar, pifeli2160@zevars.com

Physical exam Exam finding Significance

Basic metabolic panel (BMP) for azotemia, or high

Liver Panel (LFT) for low albumin

Coagulation factors (INR, PT, PTT) for coagulopathy

Elevated lactate (end organ dysfunction)

Led Joestar, pifeli2160@zevars.com

A fecal occult blood test (FOBT) is not a screening tool for

Led Joestar, pifeli2160@zevars.com

1 Establish adequate IV access:

Viscosity and Laminar Flow; Law, OpenStaxCollege, https://opentextbc.ca/physicstestbook2/chapter/viscosity-and-laminar-flow-

1 Establish adequate IV access:

1 Establish adequate IV access:

Gold standard Other options

• Upper endoscopy • Push enteroscopy

• Colonoscopy • Nuclear scintigraphy

Led Joestar, pifeli2160@zevars.com

Mr. Gibb is a 56-year-old man with chronic knee pain who

What is the best next step in management?

Led Joestar, pifeli2160@zevars.com

Mr. Gibb is a 56-year-old man with chronic knee pain who

Answer: establishing adequate IV access, aggressive fluid

In this lecture, you have learned how to...

 distinguish between an upper and

 categorize the severity of bleed

 describe appropriate initial steps in

Led Joestar, pifeli2160@zevars.com

Led Joestar, pifeli2160@zevars.com

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