Gastrointestinal bleeding

Dr. yuanyuan zhang

Scope of the problem
GI bleeding (GIB) may occur at any age, most commonly
between 40 and 79 years of age. Moretality is highest
after the age of 60 years.
GIB is divided into upper (UGIB) and lower (LGIB).
UGIB occurs in 50–150/100,000 adults each year.
There are 250,000 hospital admissions each year for UGIB,
with costs of almost $1 billion.
Scope of the problem
Bleeding may occur anywhere along the gastrointestinal (GI)
tract.
Severity of bleeding may range from asymptomatic rectal
bleeding to circulatory collapse from massive blood loss.
The seriousness of the disorder may be difficult to assess
initially, presenting a diagnostic and therapeutic
challenge for emergency physicians.
Anatomic essentials
The ligament of Treitz crosses the small intestine at the
junction of the duodenum and jejunum. Bleeding above
the ligament of Treitz is considered UGIB; below this
ligament it is considered LGIB.
Hematemesis is the vomiting of blood.
Coffee-ground emesis is from GIB in which blood has been
in the stomach long enough to have been partially
digested by stomach acid.
The passing of maroon or dark red stools is called
hematochezia.
 History
Where are you seeing blood?
Patients can have blood either in their vomitus (hematemesis)
or in their stool (hematochezia).
Have you had vomit that looked brown or like coffee
grounds?
These are symptoms of UGIB.
Have you had dark black, tarry, or sticky stool (melena)?
Melena occurs in about 70% of patients with UGIB and a third
of patients with LGIB.
 History
How much bleeding have you had?
If possible, try to have the patient quantify their blood loss as
a
teaspoon or less, between a teaspoon and a cup, or more than
a cup of blood.
When did the bleeding start?
Is the bleeding painful or painless?
Did you have vomiting or retching prior to hematemesis?
This suggests a Mallory–Weiss tear of the esophagus.
What other symptoms do you have?
Are you dizzy or lightheaded? Are you having chest pain or
 History
What medications do you take?
Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) can
increase the likelihood of bleeding gastric ulcers.
Iron ingestion by a child can cause UGIB.
Patients on warfarin or outpatient heparin injections can have significant
GIB.
Steroids increase the likelihood of UGIB.
Do you drink alcohol?
Alcohol use increases the likelihood of gastritis.
It also can contribute to coagulopathy and liver disease.
Alcoholic cirrhosis can progress to portal hypertension with associated
esophageal varices and hemorrhoids.
 Physical examination
The primary goal of the physical examination is:
-to assess the severity of the patient’s illness and
the amount of blood loss.
-establish the location of GIB.
 Physical examination
General appearance
The appearance of cool, clammy, pale skin, decreased level of
consciousness, and/or respiratory distress is concerning, as
it implies that the patient is acutely ill, in shock, and in need
of immediate resuscitation.
Vital signs
Signs of blood loss can be identified in the vital signs.
 Physical examination
Head, eyes, ears, nose, and throat
Observe for signs of liver disease such as icteric sclera.
Conjunctivae can give a clue to anemia and blood loss if they are pale.
Observe the oropharynx for any signs of bleeding from the nose or throat.
Skin
The skin should be examined for purpura or petechiae, suggesting an
underlying coagulopathy.
Observe for stigmata of liver failuresuch as spider angiomata, palmar
erythema and jaundice.
 Physical examination
Abdomen
Observe for distension.
Auscultate for either increased or decreased bowel sounds, although this
finding is nonspecific.
Palpation may reveal discomfort in the epigastric region. This can be
associated with an ulcer or gastritis.
An enlarged or tender liver may be a clue to liver disease.
This dilation of abdominal wall veins occurs in portal hypertension.
Ascites suggests liver disease with possible coagulopathy or portal
hypertension.
 Diagnostic testing
Occult blood
The presence of hemoglobin (Hgb) in the stool is detected.
Complete blood count
Serial Hgb measurements are more useful for assessing the degree of
blood loss.
An Hgb less than 10 g/dL suggests significant blood loss. Low Hgb may
be chronic, and comparison with previous values should be pursued.
An Hgb less than 8 g/dL (hematocrit (Hct) lessthan 25 %) usually
requires blood transfusion. With fluid therapy, the red blood cell mass
becomes diluted and the Hgb decreases.
The white blood count (WBC) may be elevated in infectious diarrhea or
inflammatory bowel processes.
Low platelet counts increase the likelihood of bleeding and should be
corrected if less than 50,000/ml and bleeding is ongoing.
 Diagnostic testing
Blood urea nitrogen and creatinine
Blood urea nitrogen (BUN) greater than 36mg/dL may suggest GIB in
the appropriate clinical setting. It becomes elevated as the protein in
blood is digested and absorbed from the GI tract, raising the serum
urea level.

Type and crossmatch

Whenever the patient’s condition allows, it is preferable to provide type-
specific blood for transfusion.

Prothrombin time
Patients with liver disease, vitamin K deficiency, or taking warfarin may
have a coagulopathy that requires correction to stop the bleeding.
 Diagnostic testing
Electrocardiogram
Cardiac ischemia may be precipitated by GIB.
Any patient over 50 years of age, with a history of heart disease,
significant anemia, hypotension, chest pain, shortness of breath, or
other evidence of shock should have an electrocardiogram (ECG).
The ECG may reveal evidence of ischemia or infarction in the setting of
GIB. If ECG changes are seen, early emergent transfusion should be
pursued.
 Diagnostic testing
Nasogastric tube
A nasogastric (NG) tube should be placed in all patients with UGIB. It is
important for determining the location and degree of bleeding.
An NG tube may show active bleeding or coffee-ground material. In
10–15% of UGIB patients, bright red blood or clots are found.
If no blood or coffee grounds are found in the NG effluent, the tube can
usually be removed.
In the case of esophageal varices, an NG tube can be placed carefully. Do
not force the tube if resistance is met.
 General treatment
Principles
The initial treatment approach is the same for upper and lower GI
bleeding.
Recognition of acutely ill patients is paramount. As with all emergency
patients, airway, breathing, and circulation are attended to first.
Supplemental oxygen, a cardiac monitor, and two large-bore intravenous
(IV) catheters (18 G or larger) should be placedimmediately.
If hypotension, tachycardia, or obvious ongoing blood loss is detected,
resuscitation should be initiated with a crystalloid bolus, followed
by early transfusion.
 General treatment
Upper gastrointestinal bleeding
Esophagogastroduodenoscopy(EGD)
EGD is both diagnostic and in many cases therapeutic.
Endoscopy provides visual evaluation of the esophagus, gastric mucosa,
and the proximal duodenum. If performed within 12–24 hours of
hemorrhage, EGD identifies lesions in 78–95% of UGIB patients.
It allows localization of bleeding, as well as an opportunity for
therapeutic intervention.
Esophageal varices can either be sclerosed, injected, or banded. Bleeding
gastric or duodenal ulcers can be injected and sclerosed if visualized.
If complete perforation is detected, surgery can be pursued.
 General treatment
Antacids
Antacids should not be used for the treatment of UGIB. They have not
been shown to decrease the incidence of bleeding. Antacids also can
make urgent or emergent EGD difficult by coating the esophageal or
gastric mucosa.
Somatostatin and octreotide
These are vasoactive proteins that cause selective constriction of the
splanchnic vascular bed and decrease gastric acid secretion. The use of
these medications decreases blood flow to the esophagus, stomach, and
duodenum, usually decreasing blood loss from UGIB.
Vasopressin
Vasopressin is a vasoconstrictor which effects the entire circulatory
system, including the splanchnic bed. It is extremely potent and should
be used in an exsanguinating patient, when endoscopy is unavailable or
not possible.
 General treatment
Histamine blockers and proton pump inhibitors
Histamine (H2) blockers and proton pump inhibitors (PPIs) decrease the
acid secretion which
contributes to gastric or duodenal ulcer formation.
These medications are routinely given to patients with UGIB, not to stop
the bleeding, but to initiate ulcer or gastritis treatment. This may
reduce further bleeding in the future.
Esophageal tamponade
Direct pressure (tamponade) of bleeding esophageal varices may be
performed when vasoactive medications are not effective, and
endoscopy is either ineffective or unavailable.
Tamponade may temporarily control severe hemorrhage in up to 80% of
patients with bleeding esophageal varices. It can be used for 12–24 hours.
 General treatment
Tamponade may be accomplished with a specialized gastric tube that
incorporates two expanding balloons. One balloon is first expanded in
the stomach. A second balloon is then expanded in the esophagus. There
is a suction eye at the tip.

The Sengstaken–Blakemore tube is the usual

multilumen tube used for tamponade

Esophageal tamponade carries significant

complications, including esophageal rupture,
airway compression from the esophageal tube,
and aspiration.
Most cases of UGIB can be controlled with
endoscopy or medications, but tamponade
remains an effective modality for extreme cases.
 General treatment
Surgery
This is the final option for a severe UGIB.
Cases where bleeding does not stop or significantly decrease after
medication use, endoscopy, or tamponade need surgical intervention.
 General treatment
Differential diagnosis of upper gastrointestinal bleeding