An Approach To:
Gastrointestinal Bleeding
Amir Surmawala PGY 2 Bruyere Family Medicine
Upper vs. Lower Obscure | Occult
Classification Upper gastrointestinal bleeding: Bleeding that originates from the gastrointestinal (GI) tract proximal to the ligament of Treitz (the junction of the duodenum and jejunum).
Lower gastrointestinal bleeding: Bleeding distal to the ligament of Treitz, and thus includes bleeding sources in the small bowel and colon. It is sometimes subcategorized as bleeding from the small bowel vs. bleeding from the colon.
Definitions ❖
Hematochezia: passage of bright red blood per rectum
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Melena: stools that appear black and tar-like (see picture)
Upper GI Bleeding - DDX ❖
Peptic Ulcer Disease (~50%): Gastric vs. Duodenal
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Inflammatory: Esophagitis (CMV, Medication), Gastritis (10-20%), IBD (Crohn’s)
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Varices: Esophagus (10-30%) vs. Stomach
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Structural: Mallory-Weiss tear (10%); Boerhaave’s syndrome; Dieulafoy’s lesion; AVM; Aortoenteric fistula; Hemobilia
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Tumor: Esophagus, Stomach, Duodenum
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Other: Epistaxis, Hemoptysis, Coagulopathy
Severe esophagitis Bleeding esophageal varix
Duodenal ulcer with a visible vessel
Lower GI Bleeding - DDX ❖
Upper GI Source with Brisk Bleeding (>1000mL)
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Infectious: SECSY (Salmonella, E.coli - EHEC, EIEC, Campylobacter + C.diff, Shigella, Yersinia). Amoeba.
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Inflammatory: Crohn’s and Ulcerative Colitis, Radiation Colitis
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Ischemic: Ischemic colitis
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Tumor: Colorectal, Small bowel, Polyp
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Structural: Diverticulosis (R>L), Angiodysplasia, Intussusception, Meckel’s Diverticulum, Anorectal: Hemorrhoids, Anal Fissure
Ulcerative colitis
Blood vessel within a colonic diverticulum
Angiodysplasia of the colon Ischemic colitis on colonoscopy
Immediate Resuscitation ❖
1. ABC’s: 2 Large bore peripheral IVs, Crossmatch Blood, Start Transfusion if indicated
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2. Immediate evaluation: NG, Postural changes, ECG, Trop, Urea
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3. Reverse anticoagulation
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4. Transfusion target: Start if Hgb Hematemesis > Coffee ground emesis > Melena > Occult blood in stool EtOH abuse, intoxication, emesis
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Liver Disease
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PMHx: PUD, H.pylori, Renal disease, Heart disease
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Hematochezia, Occult Blood. Rarely Melena
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Abd pain, fever, diarrhea
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PMHx: IBD, cancer, diverticulosis
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Meds: AC, NSAIDs
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Last Meal
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Constitutional symptoms
GI Bleed - Physical UPPER
LOWER
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Signs of Cirrhosis
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Bloody NG Aspirate (Occult Blood testing not validated)
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Obvious signs of HEENT bleed
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Mass, Hemorrhoid or fissure on rectal examination
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ABC’s and Vitals
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Signs of Hypovolemia: *Postural Changes (SBP >20, DBP>10, Pulse >30)
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Abd. Exam, Rectal exam +ve for Occult Blood
GI Bleed - Investigation UPPER ❖
LOWER
BUN/Creatinine ratio >20 OR Urea/Creatinine ratio >100 ❖
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Stool C&S, O&P, C.diff toxin
Due to degradation of blood cells and absorption of protein
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CBC, lytes, Cr, urea, type/crossmatch, PTT, INR, LFT’s, bilirubin, albumin
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CXR, AXR, CT Scan
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Upper and Lower Endoscopy
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Angiography, RBC Scan
Angiography vs. RBC Scan ❖
If source not found via Endoscopy:
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FASTER Bleed (>0.5ml/min): Angiography. ❖
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Embolization
SLOW Bleed (
