GI Bleeding:
From Mouth to Rectum
Bahasan :
• Epidemiologi and Risk Factors
• Signs and Symptoms
• Physical Exam
• Etiologi
• Diagnosis
• Managemen
GASTROINTESTINAL BLEEDING
• Hematemesis
• Melena
• Hematochezia
• Occult bleeding
Epidemiology Key Point: Mortality LGIB
< UGIB < Variceal bleeds
• Upper GI bleeds (UGIB)
▫ 100,000 admissions/year to US hospitals
▫ 10% mortality
• Variceal bleeds
▫ 30% varices esofagus/Gaster will bleed in 1 year
▫ 33% mortality with each bleed
• Lower GI bleeds (LGIB)
▫ Less common than UGIB
▫ 3% mortality
Risk Factors
Most Important Part of History!
• NSAID
• Cirrhosis Varises Bleeding
• Anticoagulation/Coagulopathy
• Age
• Risk factors colon cancer
• Previous history of GI bleeding
History
• Present illness
▫ source, magnitude, duration of bleeding
▫ associated GI symptoms (vomiting, diarrhea, pain)
▫ associated systemic symptoms (fever, rash, joint pains)
• Review of systems
▫ GI disorders, liver disease, bleeding diatheses
▫ medications (NSAID’s, warfarin)
• Family history
Signs and Symptoms
Upper GI Bleed Lower GI Bleed
▫ Lightheadedness/Syncope ▫ Lightheadedness/Syncope
▫ Diarrhea ▫ Diarrhea
▫ Anemia ▫ Anemia
▫ Hematemasis ▫ Hematochezia
▫ Melena
▫ Stigmata of cirrhosis
▫ Heartburn
Definitions
• Melena: passage of black, tarry stools; suggests
bleeding proximal to the ileocecal valve
• Hematochezia: passage of bright or dark red blood
per rectum; indicates colonic source or massive
upper GI bleeding
• Hematemesis: passage of vomited material that is
black (“coffee grounds”) or contains frank blood;
bleeding from above the ligament of Treitz
• Occult Bleeding:
Physical Exam Findings
• Vital signs
• Dry mucus membranes
• Stigmata of cirrhosis
• Fetid breath
• Weak pulses
• Cool skin
• Encephalopathy
Physical examination
• Vital signs, including orthostatics
• Skin: pallor, jaundice, ecchymoses, abnormal
blood vessels, hydration,
• Nasopharyngeal injection, tonsillar enlargement,
bleeding
• Abdomen: organomegaly, tenderness, ascites,
caput medusa
• Perineum: fissure, fistula, induration
• Rectum: gross blood, melena, tenderness
Further assessment
• Is it really blood?
• Hemoccult stool, gastroccult emesis
• Nasogastric aspiration and lavage
• Clear lavage makes bleeding proximal to
ligament of Treitz unlikely
• Coffee grounds that clear suggest bleeding
stopped
• Coffee grounds and fresh blood mean an active
upper GI tract source
Common Etiologies
Upper GI Bleed Lower GI Bleed
• PUD – 55 % • Diverticular disease – 30%
• Varices – 14 % • Colitis – 18%
• AVMs – 6% ▫ Ischemic
• Mallory Weiss Tears – 5% ▫ Inflammatory
• Tumors/Erosions – 4% ▫ Infectious
• Dieulafoy’s lesions – 1% • Neoplasms – 10%
• Others 15% • AVMs – 8%
• Hemorrhoids – 5%
• Others – 20%
Khilani et all, Emerg Med 37(10):27-32, 2005
Diagnosis
• Upper or Lower?
▫ History
▫ Digital Rectal Exam
▫ Hemoglobin
• Still bleeding?
▫ Consider NG Lavage
• What’s the etiology?
▫ Diagnostic Testing
Diagnostic Testing
• EGD – standard for UGIB
• Colonoscopy – standard for LGIB
• Push Enteroscopy – can image through SB
• Capsule Endoscopy – good yield - can’t
intervene
• Sigmoidoscopy – rarely
• Barium studies – good to look for lesions/mass
Imaging studies and indications
• Upper GI series: dysphagia, odynophagia
• Barium enema: intussusception, stricture
• Abdominal US: portal hypertension
• Meckel’s scan: Meckel’s diverticulum
• Sulfur colloid scan, labeled RBC scan, angiography :
obscure GI bleeding
Endoscopy: indications
• EGD: hematemesis, melena
• Flexible sigmoidoscopy: hematochezia
• Colonoscopy: hematochezia
• Enteroscopy: obscure GI blood loss
Esophageal varices
Erosive esophagitis
adolescents
• Hematemesis, melena • Hematochezia
▫ Esophagitis ▫ Infectious colitis
▫ Gastritis ▫ Inflammatory bowel disease
▫ Peptic ulcer disease ▫ Anal fissures
▫ Mallory-Weiss tears ▫ Polyps
▫ Esophageal varices
▫ Pill ulcers
NSAID induced ulcers
Peptic Ulcer
Mallory-Weiss Tear
Risk of rebleeding of ulcer
• Stigmata of recent • Rate of rebleed
hemorrhage
▫ Visible vessel ▫ 40-50%
▫ Clot ▫ 25-30%
▫ Spot ▫ 10%
▫ Clean base ▫ 2-4%
Ulcer with red spot
Laboratory studies
• CBC; BUN, Cr; PT, PTT in all cases
• Others as indicated:
▫ Type and crossmatch blood
▫ AST, ALT, GGTP, bilirubin
▫ Albumin, total protein
▫ Stool for culture and parasite examination, Clostridium
difficile toxin assay
Management – General Principles
• Risk stratify
▫ Assess blood loss
▫ Blatchenford score
▫ Rockall score (after EGD)
• IV access
• Volume replacement
• Acid suppression therapy
• Plan for diagnostic procedure
Therapy
• Supportive care: begin promptly
• IV fluids, blood products, pressors
• Specific care
• Barrier agents (sucralfate)
• H2 receptor antagonists (cimetidine, ranitidine, etc.)
• Proton pump inhibitors (omeprazole, lansoprazole)
• Vasoconstrictors (somatostatin analogue, vasopressin)
• Endoscopic therapy: stabilize and prepare patient first
• Coagulation (injection, cautery, heater probe, laser)
• Variceal injection or band ligation
• Polypectomy
Management:
• IV Access
• Volume replacement
▫ Normal saline
▫ Blood tranfusion
▫ Consider FFT/Cryo/FFP
Management – Suspected Varices
• Initial stabilization
• Splanchnic Vasoconstricters:
Octreotide/Vasopressin
• TIPS
• Minnesota tube / Blakemoore tube
• Antibiotic prophylaxis
• A whole other talk
Key Points
• GI bleeding is a common hospital diagnosis
• Risk factors are the most important part of the
history
• Vital signs can help risk stratify patients
• PPIs can reduce need for surgery, rebleeding,
and death
