Gastrointestinal Bleeding

Gastrointestinal Bleeding
Background
Definition:
Internal bleeding in the digestive tract
Gastrointestinal bleeding can occur anywhere within the
gastrointestinal tract

This includes:
the esophagus leading to the stomach
the stomach itself and
the intestines
 Gastrointestinal Bleeding

Background
Infections (disease)
some medicines (drugs) and
alcohol
► can damage tissue in the GI tract and produce
bleeding
 Gastrointestinal Bleeding

Background
The diagnosis and therapy for gastrointestinal bleeding
(GIB) has evolved over the past 3 decades: 1) from
passive diagnostic esophagogastroduodenoscopy with
medical therapy

2)To active intervention with endoscopic techniques

followed by:
angiographic and
surgical approaches if endoscopic therapy failed
 Gastrointestinal Bleeding

Background
Gastrointestinal (GI) bleeding are classified into:
upper or
lower
depending on their location in the GI tract
 Gastrointestinal Bleeding
Background
► Upper gastrointestinal bleeding: Upper GI
bleeding originates in the first part of the GI tract:
the esophagus, stomach, or duodenum (first part of
the intestine)

► Lower gastrointestinal bleeding: Lower GI

bleeding originates in the portions of the GI tract
farther down the digestive system:
the segment of the small intestine farther from the
stomach, large intestine, rectum, and anus
 Upper Gastrointestinal Bleeding (UGIB)
Background:
Upper gastrointestinal (GI) bleeding (UGIB) is defined
as hemorrhage that emanates proximal to the
ligament of Treitz

It is a common and potentially life-threatening

condition

More than 350, 000 hospital admissions are

attributable to UGIB, which has an overall mortality
rate of 10%
 Upper Gastrointestinal Bleeding (UGIB)

Background:
Although more than 75% of cases of bleeding cease
with supportive measures, a significant percentage
of patients require further intervention, which often
involves the combined efforts of:
gastroenterologists
surgeons and
interventional radiologist
 Upper Gastrointestinal Bleeding (UGIB)
Background:
Race:
No well-described racial predilection for UGIB exists

Sex:
The male-to-female ratio is approximately 2:1 in both
countries
****The mortality rates are similar in both sexes

Age:
Morbidity and mortality rates increased with age; 73.2% of
deaths occurred in patients older than 60 years
Upper Gastrointestinal Bleeding (UGIB)

Background:
Anatomy
UGIB arises from branches of the:
celiac artery and
superior mesenteric artery (SMA)
 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
History
 Upper Gastrointestinal Bleeding (UGIB)
The patient history findings include:

► weakness ► dizziness

► syncope associated with:

► hematemesis (coffee ground vomitus)

► melena (black stools with a rotten odor) and

► hematochezia (red or maroon stool)

 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
History

Patients may have a history of previous:

dyspepsia (especially nocturnal symptoms) ► peptic
ulcer disease

Early satiety

and nonsteroidal anti-inflammatory drug or aspirin use

 Upper Gastrointestinal Bleeding (UGIB)
Clinical Presentation
History
Many patients with UGIB who are taking
nonsteroidal anti-inflammatory drugs present
without dyspepsia but with:
* hematemesis or
* melena as their first symptom
Clinical Presentation
History
Low-dose aspirin (81 mg) has been associated with
UGIB

Patients with a prior history of ulcers are at an

especially increased risk for UGIB when placed on:
aspirin or
NSAID therapy and
should receive continuous acid suppression with a
PPI
Clinical Presentation
History
►Because recurrence of ulcer disease is common, history
findings are relevant:

* Patients may present in a more subacute phase with a

history of:
dyspepsia and
occult intestinal bleeding
manifesting:
as a positive fecal occult blood test result or
as iron deficiency anemia
 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
History
* A history of recent aspirin ingestion suggests
that the patient may have nonsteroidal anti-
inflammatory drug gastropathy with an enhanced
bleeding diathesis from poor platelet adhesiveness
Clinical Presentation
History
A history of chronic:
alcohol use of more than 50 g/d or
hepatitis (B or C)▼

► increases the risk of:

*variceal hemorrhage
*gastric antral vascular ectasia (GAVE) or
*portal gastropathy
• Illustration: portal gastropathy
 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
History
* The presence of postural hypotension► indicates:
more rapid and
severe blood loss
Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
Physical Examination
 Upper Gastrointestinal Bleeding (UGIB)
Physical Examination
The goal of the patient's physical examination is to evaluate
for:
shock and
blood loss

Pulse and blood pressure should be checked with the patient

in :
► supine and
► upright positions
to note the effect of blood loss
 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
Physical Examination
► Significant changes in vital signs with postural
changes indicate ► an acute blood loss of
approximately 20% or more
 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
Physical Examination
► Other signs of shock include:
► extremities: cool, pale and often cyanotic
► Skin: grayish, moist, diaphoresis
► oliguria
► chest pain, dyspnea
► Tachypnea
► presyncope: lethargy, somnolence,
confusion, and delirium
 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
Physical Examination
► Other signs of shock include:
► Peripheral pulses are weak and typically rapid
► BP < 90 mmHg
 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
Physical Examination
Hematemesis and melena should be noted

►The redder the stool ► the more rapid the transit,

►►which suggests a large upper tract hemorrhage
 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
Physical Examination
Signs of chronic liver disease should be noted,
including:
spider angiomata
gynecomastia
splenomegaly
ascites
pedal edema and
asterixis
 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
Physical Examination

Signs of tumor are uncommon but portend a poor

prognosis
► Signs include:
a nodular liver
abdominal mass and
enlarged and firm lymph nodes
 Upper Gastrointestinal Bleeding (UGIB)

Clinical Presentation
Physical Examination
The finding of subcutaneous emphysema with a
history of vomiting is suggestive of Boerhaave
syndrome (esophageal perforation) and requires
prompt consideration of surgical therapy
Upper Gastrointestinal Bleeding (UGIB)

Causes
Causes
The major causes of UGIB are:
duodenal ulcer hemorrhage (25%)

gastric ulcer hemorrhage (20%)

mucosal tears of the esophagus or fundus (Mallory-

Weiss tear)

esophageal varices

erosive gastritis
 Upper Gastrointestinal Bleeding (UGIB)

Causes
erosive esophagitis

Dieulafoy lesion

gastric varices

gastric cancer and

ulcerated gastric leiomyoma

 Upper Gastrointestinal Bleeding (UGIB)

Rare Causes
Include:
aortoenteric fistula
gastric antral vascular ectasia
angiectasias and
Osler-Weber-Rendu syndrome
Remember 1:
The proportion of UGIB cases caused by peptic ulcer
disease has declined

This decline is believed to be due to the use of:

PPIs and
H pylori therapy

Patients should be considered for upper endoscopy if

blood loss from the upper gastrointestinal tract is suspected
 Upper Gastrointestinal Bleeding (UGIB)

Remember 2:
A high level of suspicion of UGIB should exist
when the patient has a history of intake of aspirin or
NSAID, even if no history of:
hematemesis or
melena exists
Remember 3:

The color of stool containing blood depends on

the transit time

Rapid transit from the upper gastrointestinal tract

can result in red or maroon stools

Melena results from more than 100 mL of blood

with moderate transit time

Slow transit of blood from the lower intestine can

result in melena in the presence of obstruction
Remember 4:
Urgent endoscopy is indicated when patients
present with:

hematemesis
melena or
postural changes in blood pressure
Remember 5:
Primary surgical intervention should be
considered in patients with a perforated viscus
from:
duodenal ulcer
gastric ulcer or
Boerhaave syndrome
Remember 6:
In patients who are poor operative candidates:

► conservative treatment with nasogastric suction

► and broad-spectrum antibiotics can be instituted

►Endoscopic clipping or sewing techniques have

also been used in such patients
 Upper Gastrointestinal Bleeding (UGIB)

Differentials Diagnosis
1) Duodenum, Ulcers
2) Esophagus: Tear , Varices, Cancer, Esophagitis,
Boerhaave syndrome

3) Gastric: Carcinoma, Ulcer, Gastritis

4) Portal Hypertension
 Upper Gastrointestinal Bleeding (UGIB)

Labworkup
CBC with platelet count.

Basic metabolic profile (BMP):

BUN
Creatinine
Electrolytes
Glucose level
Fluid balance
 Upper Gastrointestinal Bleeding (UGIB)

Labworkup
Coagulation parameter: PT, aPPT

Liver profile: The liver profile can identify:

► hepatic comorbidity and

► suggest underlying liver disease
Labworkup
Calcium level:
A calcium level is useful to identify the patient with:

► hyperparathyroidism
► as well as to monitor calcium in patients receiving multiple
transfusions of citrated blood
 Upper Gastrointestinal Bleeding (UGIB)

Labworkup
Gastrin level:
A gastrin level can identify the rare patient with
gastrinoma as the cause of:
UGIB and
multiple ulcers
 Upper Gastrointestinal Bleeding (UGIB)

Imaging Studies
Chest radiographs should be ordered to exclude:
aspiration pneumonia
effusion
esophageal perforation

Upright films should be ordered to exclude

perforated viscus and ileus
 Upper Gastrointestinal Bleeding (UGIB)

Imaging Studies
Barium contrast studies are not usually helpful and
can make endoscopic procedures more difficult (i.e.
white barium obscuring the view)
 Upper Gastrointestinal Bleeding (UGIB)

Imaging Studies
Angiography may be useful if:

► bleeding persists and

► endoscopy fails to identify a bleeding site

Imaging Studies
CT scan and ultrasonography may be indicated to
evaluate:

► liver disease with cirrhosis

► cholecystitis with hemorrhage

► pancreatitis with pseudocyst and hemorrhage

aortoenteric fistula

►and other unusual causes of upper gastrointestinal

hemorrhage
Other Tests:
An ECG should be ordered to exclude:
arrhythmia and
acute myocardial infarction
► due to hypotension

Performing a troponin test may be useful to identify patients

with:
severe coronary ischemia or
atypical myocardial infarction
 Upper Gastrointestinal Bleeding (UGIB)

Procedures
Nasogastric lavage (1):
This procedure may confirm recent bleeding (coffee ground
appearance)

Possible active bleeding (red blood in the aspirate that does

not clear)
 Upper Gastrointestinal Bleeding (UGIB)

Procedures
Nasogastric lavage (2):

A nasogastric tube is an important diagnostic tool,

and tube placement can reduce the patient's need to
vomit

Placement for diagnostic purposes is not

contraindicated in patients with possible esophageal
varices
 Upper Gastrointestinal Bleeding (UGIB)

Treatment
Medical Care
Surgical Care
 Upper Gastrointestinal Bleeding (UGIB)

Treatment
Medical Care
The goal of medical therapy is to correct:
shock
coagulation abnormalities and
to stabilize the patient
► so that further evaluation and treatment can
proceed
Treatment
Medical Care
Stabilize the patient with intravenous fluids:
* usually normal saline: except in patients with
severe liver disease, ascites, or heart failure

* and transfuse to maintain a hemoglobin level of

8-10 g

* Promptly correct any abnormalities in coagulation

* Early aggressive resuscitation can reduce
mortality in acute UGIB *
 Upper Gastrointestinal Bleeding (UGIB)

Treatment
Surgical Care
Endoscopic
Celiotomy
 Upper Gastrointestinal Bleeding (UGIB)

Consultations
Consultation with a surgeon should be considered for
all patients with gastrointestinal hemorrhage
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