Upper and lower GIT bleeding

DR. AHMED DAWAII AL-HAJJAJ

Gastrointestinal Bleeding

Upper gastrointestinal haemorrhage remains a major medical problem with an incidence of over 100/100 000
per year in Western practice. The incidence increases with age. Haemorrhage is strongly associated with NSAID
use.

A. Definitions
Upper GI bleeding refers to a source of bleeding above or proximal to the ligament of Treitz in the duodenum.
Lower GI bleeding is classically defined as bleeding below or distal to the ligament of Treitz.

B. Causes
Upper GI bleeding
a. Peptic ulcer disease (PUD): duodenal ulcer, gastric ulcer (risk factors include Helicobacter pylori
infection, NSAIDs, stress, or excess gastric acid)
b. Esophagitis.
c. Gastritis, duodenitis
d. Sequelae of portal hypertension: esophageal or gastric varices, portal hypertensive gastropathy, gastric
antral vascular ectasia (GAVE)
e. Mallory Weiss tear.
f. Angiodysplasias or arteriovenous malformations (AVMs)
g. Dieulafoy vascular malformation:submucosal dilated arterial lesions that can cause massive GI bleeding
h. Malignancy.
i. Hemobilia or hemosuccus pancreaticus (rare)
j. Aortoenteric fistulas (rare, usually iatrogenic, ask about prior aortic aneurysm/graft).

Lower GI bleeding
a. Diverticulosis (up to 50% of cases) most common source of GI bleeding in adults
b. Angiodysplasia
c. Hemorrhoids and anal fissures
d. Ischemic colitis
e. Colorectal cancer or polyps
f. IBD (UC, Crohn disease)
g. Postpolypectomy
h. Radiation colitis
i. Infectious colitis
j. Small intestinal bleeding (diagnosed by excluding upper GI and colonic bleeding).

Quick Hits
 A lower GI bleed in patients over 40 is colon cancer until proven otherwise.
 Most cases of GI bleeding stop spontaneously with supportive therapy.
 Bleeding from the small bowel may manifest as melena or hematochezia.
 Colonic sources of bleeding present with either occult blood in the stool or hematochezia.

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C. Clinical Features
1. Type of bleeding:
a. Hematemesis: vomiting blood; suggests upper GI bleeding. Indicates moderate to severe bleeding that
may be ongoing.

b. “Coffee grounds” emesis: suggests upper GI bleeding as well as a lower rate of bleeding (enough time
for vomitus to transform into “coffee grounds”).

c. Melena: black, tarry, liquid, foul-smelling stool.

• Caused by degradation of hemoglobin by bacteria in the colon; presence of melena indicates
that blood has remained in GI tract for several hours.
• The further the bleeding site is from the rectum, the more likely melena will occur.
• Note that dark stools can also result from bismuth, iron, spinach, charcoal, and licorice.
• Melena suggests upper GI bleeding 90% of the time. Occasionally, the jejunum or ileum is the
source. It is unusual for melena to be caused by a colonic lesion, but if it is, the ascending colon
is the most likely site.

d. Hematochezia:bright red blood per rectum.

• This usually represents a lower GI source (typically left colon or rectum). Consider diverticulosis,
arteriovenous malformations, hemorrhoids, and colon cancers.
• It may result from massive upper GI bleeding that is bleeding very briskly (so that blood does not
remain in colon to turn into melena). This often indicates heavy bleeding, and patient often has
some degree of hemodynamic instability. An upper GI source is present in about 5% to 10% of
patients with hematochezia.
• Occult blood in stool: source of bleeding may be anywhere along GI tract.

2. Signs of volume depletion (depending on rate and severity of blood loss).

3. Symptoms and signs of anemia (e.g., fatigue, pallor, exertional dyspnea).

Quick Hits
• Always ask patients with GI bleeding if they took any NSAIDs, antiplatelet agents (e.g., aspirin,
clopidogrel), or anticoagulants.
• Hematemesis and melena are the most common presentations of acute upper GI bleed, and patients
may have both symptoms. Occasionally, a brisk upper GI bleed presents as hematochezia.
• An elevated PT may be indicative of liver dysfunction, vitamin K deficiency, coagulation factor
deficiency, a consumptive coagulopathy, or warfarin therapy.

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D. Diagnosis
1. Laboratory tests.
a. Hemoglobin/hematocrit level (may not be decreased in acute bleeds): A hemoglobin level >7 to 8 g/dL
is generally acceptable in stable patients without active bleeding. However, patients with acute
coronary syndrome should have a higher hemoglobin level >9 to 10 g/dL. If active bleeding or if patient
is symptomatic from anemia, transfuse supportively regardless of hemoglobin threshold.

b. A low mean corpuscular volume (MCV) is suggestive of iron-deficiency anemia (chronic blood loss).
Patients with acute bleeding have normocytic or macrocytic red blood cells.

c. Coagulation profile (platelet count, PT, PTT, INR).

d. Liver function, renal function.

e. The BUN–creatinine ratio is often elevated with upper GI bleeding. This is suggestive of upper GI
bleeding if patient has no renal insufficiency. The higher the ratio, the more likely the bleeding is from
an upper GI source.
f. Hemoccult testing (FOBT or FIT) should not be used for inpatient evaluation of GI bleeding (high rates of
false positives and false negatives).

Important clinical notes:

Tests to Order in Patients with GI Bleeding
 Hematemesis: Upper endoscopy is the initial test.

 Hematochezia: First rule out an anorectal cause (e.g., hemorrhoids). Colonoscopy should be the initial
test because colon cancer is the main concern in patients over age 45.

 Melena: Upper endoscopy is usually the initial test because the most likely bleeding site is in the upper
GI tract. Proceed with colonoscopy if no bleeding site is identified from the endoscopy. Push
enteroscopy or capsule endoscopy may be used when small bowel bleeding is suspected, or source of
bleeding is not identified by upper endoscopy or colonoscopy.

 Occult blood: should only be used in outpatient setting for colorectal cancer screening. A positive test
requires colonoscopy.

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Quick Hits
 If you suspect lower GI bleeding, still exclude upper GI bleeding before attempting to localize the site of
the lower GI bleed.
HIT
 Initial Steps in any Patient with GI Bleeding
• Vital signs: Hypotension, tachycardia, or orthostatic hypotension are signs of significant
hemorrhage. However, vital signs may also be normal when significant hemorrhage is present.
• Obtain intravenous access: two large-bore peripheral IVs or large-bore sheath introducer for
unstable patients.
• Resuscitation is the first step (e.g., IV fluids, transfusion).
• Perform rectal examination to look at stool color and presence of blood.

2. Upper endoscopy: most accurate diagnostic test in evaluation of upper GI bleeding. Both diagnostic and
potentially therapeutic (coagulate bleeding vessel).

3. Colonoscopy identifies the site of the lower GI bleed in majority of cases, and is both diagnostic and
potentially therapeutic.

4. Push enteroscopy can visualize the proximal small bowel when bleeding is suspected there. Video capsule
endoscopy is another option for small bowel bleeding when upper and lower endoscopy are unrevealing.

5. Nasogastric tube lavage is no longer routinely used for diagnosis. Historically was used to determine if GI
bleed originating from an upper or lower GI source. Studies have not demonstrated benefit in clinical
outcomes.

6. Anoscopy can exclude an anal/rectal source.

7. Radionuclide scan (RBC scintigraphy) reveals bleeding even with a low rate of blood loss.
It does not localize the lesion; it only identifies active bleeding, It is not used often due to these limitations.
8. CT angiography can be used to localize active bleeding but lacks therapeutic capability.

9. Angiography definitively locates the point of bleeding, but is reserved for patients in whom endoscopy is
not an option due to hemodynamic instability. bleeding must be occurring at a rate of at least 1.0 to 1.5
mL/min to be detectable with this test.

a. Should be performed during active bleeding.

b. Potentially therapeutic (embolization or intraarterial vasopressin infusion).

10. Exploratory laparotomy: (rarely done, last resort). operation should not be delayed if bleeding persists.
Patients with a visible vessel in the ulcer base, a spurting vessel or an ulcer with a clot in the base are likely
to require surgical treatment.

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CLINICAL PEARL
Factors That Increase Mortality in GI Bleeding
1. Age >65 years.
2. Severity of initial bleed.
3. Extensive comorbid illnesses.
4. Onset or recurrence of bleeding while hospitalized for another condition.
5. Need for emergency surgery.
6. Significant transfusion requirements.
7. Diagnosis (esophageal varices have a 30% mortality rate) Endoscopic stigmata of recent hemorrhage.

E. Treatment
Whatever the cause, the principles of management are identical.

1. If patient is hemodynamically unstable, resuscitation is always top priority.

Remember the ABCs.
Once the patient is stabilized, obtain a diagnosis.
• Supplemental oxygen
• Place two large-bore IV lines. Give IV fluids or blood if patient is volume depleted.
the patient should be adequately resuscitated.
• Type and cross-match adequate blood (PRBCs). Transfuse as the clinical condition demands (e.g., shock,
patients with cardiopulmonary disease). usually when >30% of blood volume has been lost.

N.B:
o The adult human has approximately 5 litres of blood (70 mL/kg for children and adults, 80 mL/kg
for neonates).

Traditional classification of hemorrhagic shock.

Class
1 2 3 4
Blood volume lost as percentage of
<15% 15–30% 30–40% >40%
total

o A drop in the orthostatic blood pressure greater than 10 mm Hg or an increase in the pulse rate
greater than 10 beats/min indicates that more than 800 mL of blood (> 15% of the total
circulating blood volume) has been lost.
o Marked tachycardia and tachypnea in association with hypotension and depressed mental status
indicate that more than 1,500 mL of blood (> 30% of the total circulating blood volume) has
been lost.

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• For those with severe bleeding, central venous pressure monitoring should be established and bladder
catheterisation performed.
• Draw blood for hemoglobin and hematocrit, PT/INR, PTT, and platelet count. Monitor hemoglobin every
4 to 8 hours until the patient is hemoglobin stable for at least 24 hours.
• In some patients, bleeding is secondary to a coagulopathy. The most important current causes are liver
disease and anticoagulation therapy. In these circumstances the coagulopathy should be corrected, if
possible, with fresh-frozen plasma or concentrated clotting factors with haematology advice.

2. Treatment depends on the cause/source of the bleed

a. Upper GI bleeding
• Esophagogastroduodenoscopy (EGD) with coagulation of the bleeding vessel. If bleeding continues,
repeat endoscopic therapy or proceed with surgical intervention (ligation of bleeding vessel)
• If a bleeding ulcer is considered, start a proton pump inhibitor (PPI). Increasing gastric pH improves
clotting
• If suspecting a variceal bleed (e.g., in patients with cirrhosis)
o Fortunately, most bleeding from varices is oesophageal and is much more amenable to
sclerotherapy, banding and balloon tamponade.
o Gastric varices may also be injected, Banding can also be used, again with difficulty.
o The gastric balloon of the Sengstaken– Blakemore tube can be used to arrest the haemorrhage
from the fundus of the stomach or GOJ.
o Intravenous infusion of octreotide (somatostatin analogue) or terlipressin (Glypressin), a
vasopressin analogue, reduces portal pressure in patients with varices and is of value in arresting
haemorrhage.
o Acute surgery on bleeding varices should be avoided, if possible, because of high operative
mortality; it has been superseded in most centres by transjugular intrahepatic portosystemic
shunt (TIPSS) insertion.

b. Lower GI bleeding
• Colonoscopy: polyp excision, injection, laser, cautery
• Arteriography with embolization
• Surgical resection of involved area: last resort.
Blind segmental colectomy should never be performed.
If the bleeding site still cannot be accurately localized, subtotal colectomy is the procedure of choice.

3. Indications for angiography or surgery (usually interventional angiography is attempted prior to resorting to
surgery):
a. Hemodynamically unstable patients who have not responded to IV fluid, transfusion, endoscopic
intervention, or correction of coagulopathies.
b. Severe initial bleed or recurrence of bleed after endoscopic treatment.
c. Continued bleeding for more than 24 hours.
d. Ongoing transfusion requirement (five units within first 4 to 6 hours).

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A 37-year-old man presents with abdominal pain, mild nausea, and dark stools. The patient reports that over
the past 6 months he has noticed abdominal pain that is only alleviated by eating. He has gained 6.8 kg (15 lb)
during this time period. The patient denies alcohol or illicit drug use, but does report headaches for which he
takes over-the-counter acetaminophen. Physical examination reveals melena on rectal examination, but is
otherwise unremarkable.
Which of the following is the most likely diagnosis?
A. Peptic ulcer disease
B. Diverticulosis
C. Colon cancer
D. Mesenteric ischemia

The answer is
A: Peptic ulcer disease. This patient is presenting with melena (dark tarry stools) and abdominal pain. Peptic
ulcer disease is the most common cause of upper GI bleeds, and is suggested by the history. Symptoms from
duodenal ulcers are often relieved by eating, and thus are associated with weight gain.

(B) Diverticulosis is usually asymptomatic; however, if it is associated with GI bleeding, it is typically bright red
bleeding.
(C) Colon cancer should always be considered, but this is a young patient with weight gain, making it less likely.
(D) Mesenteric ischemia is accompanied by abdominal pain that is worse with eating. However, this patient’s
abdominal pain improves with eating.
REFERENCES:

1. Bailey & Love’s short practice of surgery

2. Step Up To Medicine 6th Edition 2024
3. ACS Surgery: Principles and Practice