Gastrointestinal (GI) Bleeding

Intraluminal blood loss anywhere from the oropharynx to the anus. Classification: upper = above the ligament of Treitz; lower = below the ligament of Treitz “Severe” GIB: defined as having associated shock, orthostatic hypotension, fall in hematocrit by 6% (or decrease in Hb by 2 g/dL), or requiring transfusion ≥2U PRBCs. Requires hospitalization.

Upper GI Bleeding (UGIB)

PUD caused by Helicobacter pyloriinfection or NSAID use is the most common cause of nonvariceal UGI bleeding. Characteristic findings are hematemesis, melena, or (infrequently) bright-red blood per rectum or a high serum BUN/creatinine ratio. Slow and/or chronic bleeding is suggested by iron deficiency and is typical of erosive disease, tumor, esophageal ulcer, portal hypertensive gastropathy, Cameron lesion (erosions found within large hiatal hernias), and angiodysplasia.

Table 10.1: Differential Diagnosis of Upper GI Bleeding

Presentation	Diagnosis
Dyspepsia, H. pylori infection, NSAID use, anticoagulation, severe medical illness	Peptic ulcer disease
Stigmata of chronic liver disease, evidence of portal hypertension or risk factors for cirrhosis (alcohol use, viral hepatitis)	Variceal bleeding
History of heavy alcohol use and retching before hematemesis, hematemesis following weightlifting, or young woman with bulimia	Mallory-Weiss tear
Heartburn, regurgitation, and dysphagia; usually small-volume or occult bleeding	Esophagitis
Progressive dysphagia, weight loss, early satiety, or abdominal pain; usually small-volume or occult bleeding	Esophageal or gastric cancer
NSAID use, heavy alcohol intake, severe medical illness; usually small-volume or occult bleeding	Gastroduodenal erosions

Initial management

Assess severity: vital signs including orthostatic changes, JVP. Tachycardia (can be masked by βB use) suggests 10% volume loss, orthostatic hypotension 20% loss, shock >30% loss. After the patient is stabilized, upper endoscopy is required to document the source of bleeding. If upper endoscopy shows an ulcer, test for H. pylori infection.

Resuscitation: placement of 2 large-bore (18-gauge or larger) intravenous lines, volume replacement: NS or LR to achieve normal vital signs, urine output, and mental status.

Pharmacological Treatment For variceal bleeding refer to (10.4.2.3 Bleeding Esophageal Varices)

For bleeding peptic ulcer disease

C: pantoprazole (IV) 40mg 12hourly for 2-3days

S: esomeprazole (IV) 40mg 12hourly for 2-3days

Note:

Treat high-risk ulcers endoscopically (haemoclips, thermal therapy, or injection therapy) and continuous IV PPI infusion for 72 hours. Blood transfusion to target haemoglobin level of 7 g/dl Repeat endoscopic therapy for continued bleeding
Surgery or interventional radiology if endoscopic therapy unsuccessful

Laboratory Investigations

FBP, LFT, RFT.

Abdominal ultrasound

Viral hepatitis screening

H. pylori stool antigen

Lower gastrointestinal (GI) Bleeding

Acute, painless LGI bleeding in older adult patients is usually due to colonic diverticula or angiodysplasia. Ten percent of rapid rectal bleeding has an UGI source.

Consider outpatient follow-up or early discharge when:

patient age <60 years
no hemodynamic instability
no evidence of gross rectal bleeding
identification of an obvious anorectal source of bleeding

Table 10.2: Differential Diagnosis of Lower GI Bleeding

Presentation	Diagnosis
Painless, self-limited, massive hematochezia	Diverticular bleeding (most common overall cause)
Chronic blood loss or acute painless hematocheziain an older adult patient	Angiodysplasia
Stool positive for occult blood in an asymptomatic patient	Colonic polyp or cancer
Risk factors for atherosclerosis and evidence ofvascular disease in an older adult patient; typically,with LLQ abdominal pain	Ischemic colitis
Aoritc stenosis	Angiodysplasia (Heyde Syndrome)
History of bloody diarrhea, tenesmus, abdominal pain, fever	IBD
Rapid UGI bleeding	Dieulafoy lesion (large, tortuous, submucosalarteriole)
Large hiatal hernia	Cameron lesion (mucosal erosions)
Recent liver or biliary procedure	Hemobilia
Necrotizing pancreatitis	Hemosuccus pancreaticus (bleeding frompancreas)
Aortic aneurysm repair	Aortoenteric fistula
Painless hematochezia in a young patient and normal upper endoscopy and colonoscopy	Meckel diverticulum
Mucocutaneous telangiectasias	Hereditary hemorrhagic telangiectasia

Note:

According to expert opinion, the blood transfusion threshold for patients with colonic bleeding is a haemoglobin value <9 g/dL (note this is different for the evidence-based threshold for UGI bleeding).
If the patient is hemodynamically unstable, resuscitate the patient before diagnostic studies are performed. Most episodes of LGI bleeding resolve spontaneously.
Colonoscopy is recommended early, usually within the first 48 hours of admission, and endoscopic therapy is used to control continued bleeding.
If colonoscopy does not identify a discrete lesion or endoscopic therapy does not control the bleeding, interventional angiography or surgery may be indicated.
Patients with angiodysplasia in the setting of AS (Heyde Syndrome) may benefit from valve replacement surgery.

Bleeding of Obscure Origin

Obscure GI bleeding is recurrent blood loss without an identified source of bleeding despite upper endoscopy and colonoscopy.Patients aged ≤50 years are more likely to have tumors (leiomyomas, carcinoid, adenocarcinoma, or lymphoma), Dieulafoylesion, or Crohn’s disease. Older patients are more likely to have vascular lesions, such as angiodysplasia. Angiodysplasia is the most common cause of obscure GI bleeding overall (40% of all cases). Patients may present with either melena or hematochezia or positive fecal occult blood test (FOBT). The first step is to repeat upper endoscopy and/or colonoscopy, which is diagnostic in approximately 40% of cases.

For patients with obscure active GI bleeding

nuclear studies (technetium 99m-labeled erythrocyte or sulfur colloid nuclear scan) first, followed by angiography
if unrevealing consider push enteroscopy or balloon-assisted enteroscopy (deep enteroscopy)
surgery and intraoperative enteroscopy is a last diagnostic option

For patients with occult GI bleeding

capsule endoscopy (first choice GIE 2015; 81:889) or deep enteroscopy
if unrevealing, repeat endoscopic examinations (upper endoscopy, colonoscopy, capsule endoscopy), or deep enteroscopy