Gastrointestinal Hemorrhage

• Defnition: blood coming out of the body through

mouth or anus
• Overt (visible)
– hematemesis (vomiting of blood or coffee-ground like
material)
– melena (black, tarry stools)
– hematochezia (passage of maroon or bright red blood or
blood clots per rectum).
– Blood mixed with stool and mucus can produce a
characteristic jellylike or currant-jelly stool. This may
originate from a Meckel's diverticulum, particularly in
children
• occult ( not seen by necked eye)
 Lower Gastrointestinal Hemorrhage
• blood loss of recent onset originating from a site distal to the
ligament of Treitz
• Causes:
- Diverticulosis -33%
- Cancers/polyps -19%
-Colitis/ulcers (including inflammatory bowel disease,
infectious, ischemic,and radiation colitis,vasculitis and
inflammation of unknown cause) — 18 percent -
Unknown — 16 percent
-Angiodysplasia — 8 percent
- Miscellaneous (postpolypectomy, aortocolonic fistula,
stercoral ulcer, anastomotic bleeding)
-Anorectal (hemorrhoids, fissures, and idiopathic rectal
ulcers)
-Small intestinal sources account for 0.7% to 9% of cases of
acute lower GI bleeding(70% to 80% AVMs; other, jejunoileal diverticula,
Meckel's diverticulum, neoplasia, regional enteritis, and aortoenteric fistulas )
 under age 50 in whom hemorrhoids are the most common cause
of rectal bleeding
• Diverticulosis — A diverticulum is a sac-like
protrusion of the colonic wall
- 75 % of diverticula occur on the left side of the
colon and, when right-sided diverticula do occur,
they are usually associated with left-sided
diverticula
-In increased ages
-painless except for mild crampy abdominal
discomfort
-self-limited in over 70 to 80 percent of cases.
• Angiodysplasia — Angiodysplasia refers to
dilated tortuous submucosal vessels
– may occur throughout the colon, although
bleeding most often originates from the cecum or
ascending colon
– usually is overt, presenting with painless
hematochezia or melena.
– Bleeding is venous in origin (in contrast to arterial
bleeding with diverticula) and therefore tends to
be less massive than diverticular bleeding
• Colitis : Infectious, ischemia-related colitis
because of relative hypotension, heart failure, or
arrhythmia, Inflammatory bowel disease refers to
both Crohn's disease and ulcerative colitis
• Neoplasm — Colon cancer is a relatively less
common but serious cause of hematochezia.
– 10 percent of cases of rectal bleeding in patients over
age 50
– result of overlying erosion or ulceration.
– Bright red blood suggests left-sided lesions; right-sided
lesions can present with maroon blood or melena
 Evaluation
• History
– Type,amount,frequency,pain,
– Other associated symptom like anoroxia,nausea,
vomitting,fever
– Previous history
– History of known medical illness,radiation
– Also rule out UGIB causes
Initial studies
• Anorectal examination if the source of
bleeding is a hemorrhoid, anal fissure, anal
carcinoma, or other anorectal lesion.
• bleeding site in the upper GI tract must be
ruled out.
– A nasogastric tube
– Endoscopy to rule out upper GI bleeding with
absolute certainty
• A bleeding site in the lower GI tract must be located
– Anoscopy
– Rectoscopy
– Sigmoidescopy
– Colonoscopy : is unsatisfactory and may be dangerous
when lower GI bleeding is rapid: Visualization is poor, and
there is a risk of colon perforation
– Enteroscopy(Push enteroscopy, Intraoperative
enteroscopy, Double-balloon enteroscopy)
Subsequent diagnostic tests whether the bleeding stops
or continues
• If bleeding stops, the following steps are
taken.This occurs in 75% of patients
– A barium enema, a colonoscopy, or both
procedures should be performed:
• To identify or rule out diverticulosis or colon carcinoma
• To provide indirect evidence for colonic mucosal
ischemia
– The patient should be monitored thereafter.
• If bleeding continues, further diagnostic studies
should be done to identify the source more
precisely in preparation for surgery, if it becomes
necessary.
– If bleeding continues, a barium enema should not be
performed
– Angiography:see 80% of bleeding site,angiodysplasia
– Radionuclide scan sensitive enough to detect a
bleeding site when the rate is as low as 0.10
mL/minute
 Management
• Resuscitation with blood and intravenous fluids is
begun immediately.
• Diagnosis
• lower GI bleeding stops spontaneously in 75%
• Managing specific cause
• Treatment options include endoscopic therapy,
angiographic therapy, and surgical resection
• Indication for surgery is persistent bleeding
 Upper GI hemorrhage
• Causes
Duodenal ulcer
Gastric ulcer
Diffuse erosive gastritis
Esophgitis
Esophageal or gastric varices
Mallory-Weiss tear of the gastroesophageal junction
Gastric carcinoma
Arteriovenous malformations
• History
– information about previous episodes of GI bleeding

– current medications (e.g., aspirin or warfarin use),

– related diseases (e.g., hematologic disorders,
alcoholism, peptic ulcer disease, and recent episodes
of vomiting).
• Physical examination
– a search for evidence of nasopharyngeal bleeding,
portal hypertension, weight loss, malignancy, or
systemic diseases such as chronic hepatic or renal
failure
• Investigation
– CBC
– Bleeding profile
– Organ function test
– Passage of a nasogastric tube
– Endoscopy
– Upper GI series
– Angiography and radionuclide scanning
 Treatment
• Resuscitation measures should begin
immediately when the patient is first seen
• Medical treatment
– nasogastric tube is inserted, and the residual
thrombus in the stomach is removed with an iced
saline solution.
– Clotting factors
• Fresh frozen plasma if the prothrombin time is abnormal
• Platelets if thrombocytopenia is present
• Vitamin K if bleeding is from esophageal varices
• Histamine2 (H2) antagonists, proton pump
inhibitors (PPI), and antacids
• Vasopressin
• Fiberoptic endoscopy with sclerotherapy
• Angiography for embolization of the bleeding
vessel or by intra-arterial administration of
vasopressin.
• Balloon tamponade
• Indications for surgery
– Exsanguinating hemorrhage
– Profuse bleeding, especially in association with hypotension. Patients
should be treated surgically:
– If more than 4 U of blood are required for initial resuscitation
– If bleeding continues at a rate of more than 1 U every 8 hours
– If a brief hypotensive episode could have catastrophic results, as in patients with
coronary artery disease or cerebrovascular disease or in patients older than 60 years of
age
– Continued hemorrhage despite resuscitation and other treatment
– Recurrent bleeding after its initial cessation
– Pathologic features of the bleeding site that increase the risk of
recurrent bleeding include:
• A posterior duodenal ulcer with the gastroduodenal artery visible in its base
• A giant gastric ulcer
• Special situations may call for a modification
of the usual routines of management.
– A patient with a rare or hard-to-find blood type
should be operated on while blood is still
available.
– A patient who refuses blood transfusion for any
reason should undergo surgical exploration early.
– A patient with a coagulopathy should have the
disorder corrected, if possible, prior to surgical
exploration