GASTROINTESTINAL BLEEDING
Dr. Ronald V. Romero | October 5, 2017
5.3 GI BLEEDING
Transcribed by: Aquino-Presentacion, Baltar,
Camit, Salvadora, Tan, Angelo
OUTLINE:
• Sources of gastrointestinal bleeding
1. Upper gastrointestinal sources of bleeding
2. Small-intestinal sources of bleeding
3. Colonic sources of bleeding
• Approach to the patient
4. Differentiation from UGIB to LGIB
5. Diagnostic evaluation
GASTROINTESTINAL BLEEDING
Peptic Ulcers
® Hematemesis is vomitus of red blood or "coffee-grounds"
® Characteristics of an ulcer at endoscopy provide important
material
prognostic information
® Melena is black, tarry, foul-smelling stool
® 1/3 of patients with active bleeding or a non-bleeding visible
® Hematochezia is the passage of bright red or maroon blood vessel have further bleeding that requires urgent surgery
from the rectum
® These patients clearly benefit from endoscopic therapy with
® Occult GI bleeding (GIB) may be identified in the absence of bipolar electrocoagulation, heater probe, injection therapy
overt bleeding by a fecal occult blood test or the presence of
® Patients with clean-based ulcers have rates of recurrent
iron deficiency
bleeding approaching zero
® Symptoms of blood loss or anemia such as light headedness,
® Patients without clean-based ulcers should usually remain in
syncope, angina, or dyspnea.
the hospital for 3 days, as most episodes of recurrent bleeding
UPPER GASTROINTESTINAL BLEEDING (UGIB) occur within 3 days
® Omeprazole 80-mg bolus and 8-mg/h infusion to sustain
® Patients rarely die from exsanguination; rather, they die due to intragastric pH > 6 and enhance clot stability
decompensation from other underlying illnesses ® 1/3 of patients with a bleeding ulcer will rebleed within the
® The mortality rate for patients <60 years in the absence of next 1–2 years
major concurrent illness is <1% ® Eradication of H. pylori in patients with bleeding ulcers
® Independent predictors of re-bleeding and death in patients decreases rates of re-bleeding to <5%
hospitalized with UGIB include increasing age, comorbidities, ® If a bleeding ulcer develops in a patient taking NSAIDs,
and hemodynamic compromise (tachycardia or hypotension) DISCONTINUE the NSAIDs.
® Peptic ulcers are the most common cause of UGIB, ® If NSAIDs needs to be continued, initial treatment should be
accounting for up to ~50% of cases with a PPI co-therapy to a traditional NSAID
® Mallory-Weiss tears account for ~5–10 or 15% of cases
® The proportion of patients bleeding from varices ~5 to 30%
® Hemorrhagic or erosive gastropathy (e.g., due to NSAIDs
or alcohol) and erosive esophagitis often cause mild UGIB,
but major bleeding is rare.
Page 1 of 4
GASTROINTESTINAL BLEEDING
Mallory-Weiss Tear ® Common factors associated are: NSAID use, alcohol intake,
and stress.
® Half of patients who chronically take NSAIDs have erosions
(15-30% has ulcers.)
® Up to 20% of actively drinking alcoholic patients with UGIB
have evidence of subepithelial hemorrhages or erosion.
® Stress-related gastric mucosal injury occurs only in extremely
sick patients or high-risk patients.
o Mortality rate in these patients is quite high because of
their underlying illnesses.
o Prophylactic therapy decreases bleeding but not the
mortality rate
® Other causes:
1. Erosive duodenitis
® Classic history with vomiting, retching, or coughing preceding 2. Neoplasm
hematemesis in an alcoholic patient. 3. Aortoenteric fistulas
® Occurs at the gastric side of the gastroesophageal junction. 4. Vascular lesions - including Osler-Weber-Rendu.
® Spontaneously stops in 80-90% of patients and recurs in only 5. Gastric antral vascular ectasia “watermelon stomach”
0-7%. 6. Dieulafoy’s lesion
® For an actively bleeding Mallory-Weiss tear, an endoscopic 7. Prolapse gastropathy
therapy is indicated. 8. Hemobilia - bleeding from bile duct.
9. Hemosuccus - bleeding from pancreatic duct.
Esophageal Varices SMALL INTESTINAL SOURCES OF BLEEDING
® Has poorer outcomes ® Small-intestinal bleeding is uncommon
® For acute bleeding, endoscopic therapy is needed.
Most common causes are vascular ectasias, tumors (e.g.,
® Repeated sessions of endoscopic therapy are needed to adenocarcinoma, leiomyoma, lymphoma, benign polyps, carcinoid,
eradicate significantly which reduces bleeding and mortality. metastases, and lipoma), NSAID-induced erosions and ulcers.
® Endoscopic therapy of choice = LIGATION. ® Less common causes include Crohn's disease, infection,
® Treatment: ischemia, vasculitis, small-bowel varices, diverticula, Meckel's
o Octreotide - further helps in the control of acute diverticulum, duplication cysts, and intussusception
bleeding. Given by 50 µg bolus and 50 µg/hour IV ® Meckel's diverticulum is the most common cause of
infusion for 2-5 days. significant lower GIB (LGIB) in children
o Antibiotic therapy (e.g. Quinolones) - recommended ® In adults <40–50 years, small-bowel tumors often account
for patients with cirrhosis presenting with UGIB. for obscure GIB
o Nonselective beta-blockers (Propranolol) - ® In patients >50–60 years, vascular ectasias are usually
decreases recurrent bleeding from esophageal varices. responsible
o Transjugular Intrahepatic Portosystemic Shunt
® Vascular ectasias should be treated with endoscopic therapy if
(TIPS) - decreases re-bleeding more effectively than
possible
endoscopic therapy. Most patients with TIPS have
® Surgical therapy can be used for vascular ectasias isolated to a
shunt stenosis within 1-2 years and require re-
segment of the small intestine when endoscopic therapy is
intervention to maintain shunt patency.
unsuccessful
Hemorrhagic and Erosive Gastropathy (Gastritis) ® Isolated lesions, such as tumors, diverticula, or duplications,
® Refers to endoscopically visualized subepithelial hemorrhages are generally treated with surgical resection.
and erosions.
COLONIC SOURCES OF BLEEDING
® Considered as mucosal lesion and does NOT cause major
® The incidence of hospitalizations for LGIB is about one-fifth
bleeding.
that for UGIB
Page 2 of 4
GASTROINTESTINAL BLEEDING
® Hemorrhoids are probably the most common cause of LGIB; does not remain in the bowel long enough for melena to
anal fissures also cause minor bleeding and pain develop.
® If these local anal processes, are excluded, the most common ® When hematochezia is the presenting symptom of UGIB, it is
associated with hemodynamic instability and dropping
causes of LGIB in adults are diverticula, vascular ectasias hemoglobin
(especially in the proximal colon of patients >70 years), ® Other clues to UGIB include hyperactive bowel sounds and
neoplasms (primarily adenocarcinoma), and colitis an elevated blood urea nitrogen level (due to volume
® Diverticular bleeding is abrupt in onset, usually painless, depletion and blood proteins absorbed in the small intestine)
sometimes massive, and often from the right colon ® (Book) A non-bloody nasogastric aspirate may be seen in up
® Colonic diverticula stop bleeding spontaneously in ~80% of to ~18% of patients with UGIB, usually from a duodenal
source
patients and rebleed in about 20–25% of patients
® If bleeding persists or recurs, segmental surgical resection DIAGNOSTIC EVALUATION
is indicated UGIB
® Bleeding from right colonic vascular ectasias in the elderly ® History and physical examination are NOT usually diagnostic
may be overt or occult of the source of GIB
® Endoscopic hemostatic therapy may be useful in the ® Upper endoscopy is the test of choice in patients with UGIB
and should be performed urgently in patients with
treatment of vascular ectasias
hemodynamic instability (hypotension, tachycardia, or postural
® Surgical therapy is generally required for major, persistent, or changes in heart rate or blood pressure.
recurrent bleeding from the wide variety of colonic sources of
GIB that cannot be treated medically, angiographically, or
endoscopically.
APPROACH TO PATIENT
® Measurement of the heart rate and blood pressure is the best
way to assess a patient with GIB
® Clinically significant bleeding leads to postural changes in heart
rate or blood pressure, tachycardia, and, finally, recumbent
hypotension
® Hemoglobin does NOT fall immediately with acute GIB, due
to proportionate reductions in plasma and red cell volumes
(i.e., "people bleed whole blood")
® Hemoglobin may be normal or only minimally decreased at the
initial presentation of a severe bleeding episode
LGIB
® As extravascular fluid enters the vascular space to restore
® Patients with hematochezia and hemodynamic instability -
volume, the hemoglobin falls, but this process may take up to
UPPER ENDOSCOPY (to rule out an upper GI source
72 h
before evaluation of the lower GI tract)
® (Book) Transfusion is recommended when the hemoglobin
® Colonoscopy - procedure of choice in patients admitted with
drops below 7 g/dL, based on a large randomized trial showing
LGIB unless bleeding is too massive.
this restrictive transfusion strategy decreases re-bleeding and
death in acute UGIB compared with a transfusion threshold ® 99mTc-labeled red cell scan
of 9 g/dL. - Allows repeated imaging for up to 24
hours.
DIFFERENTIATION FROM UGIB TO LGIB - May identify the general location of
® Hematemesis (vomiting of blood, which may be obviously bleeding.
red or have an appearance similar to coffee grounds) indicates ® Angiography
an upper GI source of bleeding (above the ligament of Treitz) - Detect the site of bleeding (extravasation
® Melena (passage of dark tarry stools containing decomposing of contrast into the gut) in active LGIB.
blood) indicates that blood has been present in the GI tract for
- permits treatment with intra-arterial
at least 14 h
infusion of vasopressin or embolization
® Hematochezia (passage of fresh blood per anus, usually in or
with stools) usually represents a lower GI source of bleeding,
although an upper GI lesion may bleed so briskly that blood
Page 3 of 4
GASTROINTESTINAL BLEEDING
References
® Dr. Romero’s lecture slides and recording from lecture
® Harrison’s Principle of Internal Medicine 19th ed.
® Batch 2019’s transcription
Transer’s Message
Obscure GIB
® Persistent or recurrent bleeding for which no source has been
identified by routine endoscopic and contrast x-ray studies.
® Push enteroscopy may identify probable bleeding sites in 20–
40% of patients with obscure GIB
® Video capsule endoscopy - which allows endoscopic
examination of the entire small intestine, increases diagnostic
yield in obscure GIB.
- Patients with continued obscure GIB who
require transfusions or repeated
hospitalizations warrant further
investigations
® 99mTc-labeled red blood cell scintigraphy should be
employed
® Angiography is useful even if bleeding has subsided, since it
may disclose vascular anomalies or tumor vessels
Occult GIB
® Manifested by a positive test for fecal occult blood or iron-
deficiency anemia
® Colonoscopy - Evaluation of a positive test for fecal occult
blood generally should begin with.
**If evaluation of the colon is negative, many perform UPPER
ENDOSCOPY only if iron-deficiency anemia or upper GI
symptoms are present.
Page 4 of 4
