Upper and Lower Gastrointestinal

Bleeding

Dr. Shatdal Chaudhary MD

Assistant Professor
Department of Internal Medicine, BPKIHS, Dharan
 G I Bleeding

• Acute Vs Chronic

• Upper Vs Lower
• Bleeding above/below the ligament of Treitz
Acute U G I Bleeding

Introduction
• Most common gastrointestinal emergency
• Accounting for 50-120 admissions to hospital
per 100 000 of the population each year in
the U K.
• Higher among males, elderly
Causes of Upper GI Bleed (UGIB)
• Peptic Ulcer Disease (60% cases of UGIB)
• Erosive Gastritis(10-20%)
• Esophagitis (10%)
• Esophageal and Gastric Varices (2-9%)
• Mallory-Weiss Syndrome(5%)
• Malignancy(2%)
• Others
– Stress ulcer, arteriovenous malformation, Aorto-
duodenal Fistula, corrosive poisoning
Clinical Features:
• History: Often misleading
– Usually presents with obvious complaints (melaena,
hematemesis, etc.) or may present with more subtle signs
(hypotension, tachycardia, etc)
• Hematemesis
• Melaena
• Hematochezia
• H/o NSAIDs, Alcohol abuse, corrosive intake
• Weight loss/change in bowel habit (malignancy)
• Vomiting/retching followed by hematemesis (Mallory-
Weiss)
• Hx aortic graft (possible aortocentric fistula)
Clinical Features:
• Physical Exam
– Hypotension, tachycardia
– Skin: cool, clammy, jaundice, spider angioma and
other stigmata of CLD
– Lymph node
– Abd: tenderness, masses, ascites,
hepatosplenomegaly
– PR Exam: blood
 Estimation of blood loss
Estimated Fluid and Blood Losses in Shock

Class 1 Class 2 Class 3 Class 4

Blood Loss,
Up to 750 750-1500 1500-2000 >2000
mL

Blood Loss,%
Up to 15% 15-30% 30-40% >40%
blood volume

Pulse Rate,
<100 >100 >120 >140
bpm

Blood
Normal Normal Decreased Decreased
Pressure

Respiratory Normal or
Decreased Decreased Decreased
Rate Increased

Urine
Output, 14-20 20-30 30-40 >35
mL/h

CNS/Mental Slightly Mildly Anxious, Confused,

Status anxious anxious confused lethargic

Fluid
Crystalloid Crystalloid
Replacement, Crystalloid Crystalloid
and blood and blood
3-for-1 rule
Investigations:
Blood tests
• Blood Group
• Full blood count. Hb: may be normal or Low.
• Urea and electrolytes. may show evidence of
renal failure.
• LFT.
• Prothrombin time & Coagulation Profile.
• Cross-matching of at least 2 units of blood.
• UGI Endoscopy: Diagnostic as well as therapeutic
– should be carried out as early as possibe after adequate
resuscitation.
– A diagnosis will be achieved in 80% of cases.
– Patients who are found to have major endoscopic stigmata
of recent haemorrhage can be treated endoscopically
• Angiography: sometimes can localize, but requires
brisk bleeding rate (0.5 to 2.0 ml/min)

• Technetium-labeled red cell scan: more sensitive than

angiography
Treatment
• Primary
– ABCs
– Oxygen This should be given by facemask to all
patients in shock.
– Close monitoring

– Immediate resuscitation, 2 wide bore IV cannula

– NG tube in all patients with significant bleeding

– Consider blood transfusion if no improvement

after 2L of crystalloid or Hb < 10 gm/dL
Therapeutic Endoscopy
– Early treatment indicated when significant upper GI bleed
– Sclerotherapy or band ligation used to treat varices
– thermal modality 'heater probe‘
– injection of dilute adrenaline (epinephrine) into the bleeding
point
– application of metallic clips.
Drug Therapy
– Intravenous proton pump inhibitor infusions
reduce rebleeding
– Somatostatin and octreotide effective for reduction of acute
variceal bleeding
Balloon Tamponade
• Sengstaken-Blakemore tube can control variceal
hemorrhage in 40 – 80% patients
• Inflate gastric balloon first, the esophageal
balloon if no improvement
Surgery –
– if all other interventions are ineffective
– endoscopic haemostasis fails to stop active
bleeding
– rebleeding occurs on one occasion in an elderly
or frail patient, or twice in younger, fit patients
Prognosis:
• Mortality following a diagnosis of acute upper
gastrointestinal bleeding is approximately 10%.
RISK FACTORS FOR DEATH IN PATIENTS
WITH ACUTE U GI HAEMORRHAGE
Factor Comments
• Increasing age: Risk increases over age 60 and
especially in very elderly
• Comorbidity:Advanced malignancy; renal and
hepatic failure
• Shock: Def as pulse > 100/min, BP < 100
• Diagnosis: Varices and cancer have the
worst prognosis
• Endoscopic findings: Active bleeding and a non-
bleeding visible vessel at endoscopy
• Rebleeding Associated with 10-fold rise in mortality
Lower GI Bleeding
• Bleeding below the ligament of Treitz
• This may be due to haemorrhage from the
– small bowel
– colon or
– anal canal
• Incidence: 20 per 100,000 population
CAUSES OF LOWER GI BLEEDING
• Severe acute
– Diverticular disease
– Angiodysplasia
– Ischaemia
– Meckel's diverticulum
• Moderate, chronic/subacute
– Anal disease, e.g. fissure, haemorrhoids
– Inflammatory bowel disease
– Carcinoma
– Large polyps
– Angiodysplasia
– Radiation enteritis
– Solitary rectal ulcer
 ETIOLOGY
Differential Diagnosis of Lower Gastrointestinal Hemorrhage
COLONIC BLEEDING (95%) % SMALL BOWEL BLEEDING (5%)
Diverticular disease 30-40 Angiodysplasias
Ischemia 5-10 Erosions or ulcers (potassium, NSAIDs)
Anorectal disease 5-15 Crohn's disease
Neoplasia 5-10 Radiation
Infectious colitis 3-8 Meckel's diverticulum
Postpolypectomy 3-7 Neoplasia
Inflammatory bowel disease 3-4 Aortoenteric fistula
Angiodysplasia 3
Radiation colitis/proctitis 1-3
Other 1-5
Unknown 10-25
 Clinical Features

• OCCULT GI BLEEDING
• 'Occult' means that blood or its breakdown
products are present in the stool but cannot be
seen.
• Occult bleeding may reach 200 ml per day
Options to diagnose and control the bleeding

• Colonoscopy
• technetium-99m labeled RBC scan: requires 0.5-1
ml/min bleeding
• Mesenteric angiography: requires 1-1.5 ml/min bleeding
• Meckels scan
• Capsule Endoscopy
• Surgery

• faecal occult blood (FOB)

• Colonscopy: diagnostic and therapeutic
• colonoscopy is necessary to exclude coexisting colorectal
cancer.
– subjects who also have altered bowel habit
– and in all patients presenting at over 40 years of age,
Treatment
• Acute bleeding tends to be self limiting
• If bleeding persists perform endoscopy to exclude upper GI
cause
• Therapeutic colonoscopy
• Consider selective mesenteric embolisation if life threatening
haemorrhage
• Proceed to laparotomy and consider on-table lavage an
panendoscopy
• If right-sided angiodysplasia perform a right hemicolectomy
• If bleeding diverticular disease perform a sigmoid colectomy
• If source of colonic bleeding unclear perform a subtotal
colectomy and end-ileostomy
The End