GI Bleed

Gastrointestinal (GI) Bleeding

David Ray Velez, MD

Table of Contents

Definitions
Possible Sources
Evaluation and Management

Definitions

Classic Definitions

  • Upper GI Bleed (UGIB): Bleeding Proximal to the Ligament of Treitz
  • Lower GI Bleed (LGIB): Bleeding Distal to the Ligament of Treitz

Newer Definitions

  • Upper GI Bleed (UGIB): Bleeding Proximal to the Ligament of Treitz
  • Middle GI Bleed (MGIB): Bleeding Between the Ligament of Treitz & the Ileocecal Valve
  • Lower GI Bleed (LGIB): Bleeding Distal to the Ileocecal Valve

Presentation

  • Overt Bleeding: Bleeding is Visible to the Physician or Patient
  • Occult Bleeding: Bleeding Not Visible to the Physician or Patient
  • Obscure GI Bleeding (OGIB): Bleeding of an Unknown Source After a Negative Initial Evaluation

Overt Bleeding

  • Hematemesis: Blood in Vomitus
    • May Be Bright Red or “Coffee Ground” Black if Partially Digested
  • Hematochezia: Bright Red Blood in Stool
    • Bright Red Color Indicates that Blood Has Not Yet Digested
    • Indicates a More Distal Source
  • Melena: Dark Black-Tarry Blood in Stool
    • Dark Color Indicates that Blood Has Been Partially Digested
    • Indicates a More Proximal Source

Possible Sources

Esophagus

  • Esophageal Varices
  • Esophagitis
  • Ulcerations
  • Malignancy
  • Caustic Ingestion
  • Trauma from a Nasogastric (NG) Tube

Stomach

  • Angiodysplasia
  • Dieulafoy Lesion
  • Peptic Ulcer
  • Inflammatory Bowel Disease
  • Malignancy
  • Recent Surgery

Small Intestine

  • Angiodysplasia
  • Dieulafoy Lesion
  • Meckel’s Diverticulum
  • Intussusception
  • Inflammatory Bowel Disease
  • Radiation Enteritis
  • Mesenteric Ischemia
  • Aortoenteric Fistula
  • Malignancy
  • Recent Surgery

Large Intestine (85% of LGIB Originates in the Colon)

  • Diverticulosis – Most Common Cause of GI Bleeding
  • Angiodysplasia – Most Common Cause of Obscure GI Bleeding
  • Dieulafoy Lesion
  • Stercoral Ulcer
  • Inflammatory Bowel Disease
  • Radiation Enteritis
  • Infectious Colitis
  • Ischemic Colitis
  • Malignancy
  • Recent Colonoscopy or Biopsy
  • Recent Surgery

Rectum/Anus

  • Angiodysplasia
  • Dieulafoy Lesion
  • Inflammatory Bowel Disease
  • Radiation Proctitis
  • Hemorrhoids
  • Anal Fissure
  • Anorectal Varices
  • Local Trauma
  • Malignancy
  • Recent Surgery

Evaluation and Management

Specific Management is Individualized and Varies by Cause

Initial Evaluation

  • Thorough History and Physical Exam
  • Correct Any Coagulopathy
  • Nasogastric Tube Lavage – Detects Upper GI Bleeding
    • Gently Place a Large Bore (36-40 G) Nasogastric Tube
    • Instill 100-300 cc Warm Saline into the Stomach
    • Place the Tube to Low Intermittent Wall Suction
    • Evaluate the Fluid Removed for Blood
  • Anoscopy/Proctoscopy – Evaluates for Distal Lower GI Bleeding

Endoscopy

  • Generally the Preferred Initial Measure to Attempt Control of Bleeding
  • Esophagogastroduodenoscopy (EGD) if NG Lavage Detects an Upper GI Bleed
  • Colonoscopy if Concerned for Lower GI Bleed
    • Timing: Within 24 Hours After Adequate Bowel Prep (Yield Clear-Liquid Stools)

Secondary Management Options

  • Tagged RBC Scan
    • Indicated if Endoscopy is Nondiagnostic
    • May Detect but Poor at Localizing the Bleed
    • Minimum Bleeding Threshold: 0.05-0.1 ml/min
      • The Most Sensitive Imaging Test
  • Angiography and Embolization
    • Indications:
      • Still Unable to Localize a Bleed Despite Endoscopy and Tagged RBC Scan
      • Consider Early for Massive Bleeding
    • Minimum Bleeding Threshold: 0.5 ml/min
      • Significantly Higher Bleeding Requirement Than Tagged RBC Scan
    • Embolization May Risk Bowel Ischemia/Necrosis
  • Total Abdominal Colectomy and End Ileostomy
    • Indicated as a Last Resort if Hemodynamically Unstable and Endoscopy/Imaging is Unable to Localize
  • Capsule Endoscopy
    • Generally Not Used in the Acute Care Setting
    • Indicated for Chronic GI Bleeding that is Unable to Be Localized by Endoscopy/Imaging