Required Knowledge base to manage patients with GI Bleeding
Dr A.J. Chandrasekhar  

Patients with GI bleed can present with 

• hematemesis

• hypotension

• anemia

• black tarry stools

• Hematochezia

Bleeding can occur anywhere from oro-pharynx to rectum.

Acute bleed: hematamesis, hypotension, melena, hematochezia

Chronic bleed: anemia

Black stools  

• Bloody (Upper GI bleeding): Tarry and sticky with foul smell  Melena 

• Non-bloody (no smell and not sticky)

  • Therapeutic intake of iron

  • Pepto-Bismol (bismuth compounds)

  • Licorice.

Hypovolemia

• Lightheadedness

• Postural hypotension. A drop greater than 10 mm of Hg in erect position.

Findings supporting acute GI bleeding

• Manifestation of hypovolemia. 

  • Anxiety, lightheadedness, restlessness.

  • Pale, moist skin.  

  • Orthostasis, tachycardia 

  • Weak peripheral pulses 

• Absorption of blood 

  • Elevated BUN 

• Loss of blood 

  • Decreased hemoglobin with  normal MCV.

• Altered blood

  •  Melena per rectum. 

Likely location of bleeding site in GI tract  when there is melena

Above the ligament of Treitz. Hydrochloric acid converts Hemoglobin to 

• Duodenal ulcer

• Gastric ulcer

• Gastritis (Gastro-duodenal erosions)

• Esophagitis (GERD)

• Esophageal varices

• Mallory-Weiss tear

• Arteriovenous malformations 

• Swallowed blood from hemoptysis or orpharyngeal bleed

Amount of blood loss is required to produce each of the following:  

• Occult positive stool.  3 cc (hemoccult).

• Melena =100-200 cc

• Orthostasis=20% loss of circulating volume or about 1000 cc.

Duodenal ulcer  

• E epigastric burning with similar episodes in past. 

• Epigastric tenderness on exam.

• The history of alcohol, smoking,  NSAID’s use, aspirin use.  (predisposing factors)

Gastro-duodenal erosions. Abuse of NSAID

Esophagitis (GERD). History of reflux.

Esophageal varices. In a cirrhotic with portal hypertension. Physical findings of Cirrhosis( Spider nevi Full Parotid glands)

Mallory-Weiss tear. Retching followed by hematamesis.

Arteriovenous malformations. In a patient with stigmata for hereditary hemorrhagic telengiectasia.

Swallowed blood from hemoptysis or oropharyngeal bleed

Historical information that one should gather in evaluation of acute upper GI bleed

• Stool characteristics

  • Black

  • Sticky

  • Foul smell 

• Intake of

  • Iron

  • Pepto-Bismol (bismuth compounds)

  • Licorice

• Symptoms of hypovolemia

  • Lightheadedness

• Use of NSAID's. Can give rise to Gastritis or precipitate bleeding from Ulcers.

• Epigastric distress

• GERD symptoms

• Retching

• Nose bleeds

• History of Alcoholism, Cirrhosis and portal hypertension

• History of aortic surgery

Physical findings you  should be looking for

• Manifestation of hypovolemia. 

  • Anxiety, lightheadedness, restlessness.

  • Pale, moist skin.  

  • Orthostasis, tachycardia 

  • Weak peripheral pulses 

• Finding encountered in Cirrhosis suggesting possible esophageal varices as a source of bleeding. 

  • Spider nevi.

  • Full Parotid glands

  • Ascites

  • Hepatomegaly

  • Splenomegaly

  • Hyperestrogenism

• Finding indicating Hereditary hemorrhagic telengiectasia 

• Careful exam of Oropharynx for bleeding sites if any

Prioritized steps that should be taken in the ER to treat patients suspected of having upper GI bleeding.

• Brief history/physical exam 

• Assessing the degree of circulatory compromise by doing orthostatics. 

• Establish IV access with 2 large bore IV’s.

• Volume replacement. 

• Type and cross-match for blood. 

• Laboratory evaluation to include CBC, coags, BUN, creatinine. 

• Nasal oxygen. 

• EKG. 

• Nasogastric tube.   

• Consult with endoscopist and surgical colleagues.

• Detailed history to assess for underlying diseases which increases morbidity and mortality

Interpretation of the possible returns from nasogastric tube

• Coffee grounds = slow bleeding or oozing. 

• Red blood/clots = active ongoing bleed.  

• Bile stained = no active bleeding above the Treitz ligament. A bile stained NG aspirate would make active bleeding proximal  to the third portion of the duodenum most unlikely.  

• Clear = GI bleeding is often times intermittent and can stop spontaneously.  The clear return suggests a competent pylorus and bleeding could be still occurring in the bulb and going postbulbar. 

Ideal procedure to confirm the location of bleeding site and why? 

Once the patient has stabilized (No orthostasis, slowed pulse) an upper GI endoscopy  (EGD) would be the procedure of choice. 

• EGD is diagnostic and can be therapeutic if active bleeding or visible vessels are seen. 

• Injection therapy with epinephrine or a variety of electro coagulation techniques (heater probe, laser coagulation) can be used to stop bleeding. 

• EGD in this cases would rule out varices (a cause of severe UGI hemorrhages) 

• Also the EGD could permit a biopsy to evaluate for Helicobacter pylori, a causative agent in most peptic diseases.  A biopsy would be taken from an area of the antrum, not from or in close vicinity to bleeding lesions. 

 70/plus% of UGI bleeds will cease spontaneously. However  EGD should be done in every case

• The EGD can provide useful information (diagnosis) as well as being therapeutic in needed instances. 

• Tissue can be obtained. 

• The endoscopic findings can help assess the risk for recurrent hemorrhage (rebleeding increases mortality)

Factors that increase the mortality and morbidity from UGI bleeding.

• Rebleeding after initial presentation. 

• Severity of bleeding (>5-6 units).  

• Diagnosis (varices). 

• Age>60. 

• Multisystem disease (co-morbidity).

• Endoscopic stigmata of recent bleeding (visible vessels). 

• Onset of bleeding in hospitalized patient. 

• Need for emergency surgery for bleeding.

Patients likely to rebleed?

Patients who present with 

• hypotension  

• multiple medical illnesses

• hematemesis

• a hematocrit under 30 

• inability to clear the stomach with aggressive gastric lavage 

• Ulcer showing

  • Red spots/Ulcer base 10%

  • Clot 20%

  • Visible vessel 50%

Indication for Surgical intervention in upper GI bleeding

• Most patients can be managed with nonresectional therapy.

• Surgical intervention should be considered with  

  • large bleeding lesions in the stomach 

  • lesser curvature lesions 

  • bleeding ulcers associated with gastritis  

  • Patients who bleed after endoscopic therapy should be considered for operation after resuscitation with 6 units of blood. This is an arbitrary cutoff but is a useful marker for severity of bleeding. 

• Surgery may require subtotal or near-total gastrectomy for control of hemorrhage.

Alternative option for Surgery

Arteriography with embolization should be reserved for the unusual patient who has either a difficult location of the upper gastrointestinal bleeding or comorbidities that prohibit operation.  

Type of anemia   

• Microcytic hypochromic anemia  in chronic blood loss

• Normochromic normocytuc anemia in acute blood loss

Type of lesions that can cause chronic bleeding in GI tract

• Cancer Colon

• Cancer Stomach

• Cancer small bowel

• Hereditary hemorrhagic telengiectasia

Required evaluation for iron deficiency anemia in male adult 

• Stool for occult blood 

• Full colonoscopy.  

  • Flexible  Sigmoidoscopy  would be inadequate, as it would evaluate at best to the level of the splenic flexure. 

• If the colon was negative, then the remainder of the GI tract would have to be examined (EGD and small bowel series with barium).

Hematochezia: Bloody bowel movement

Generally indicates lower GI tract hemorrhage from the colon or distal ileum.

• Small volume Hematochezia

  • anorectal disease

  • colitis (ischemic)

  • polyps or neoplasm

• Large volume Hematochezia

  • diverticulosis

  • arteriovenous malformation

Melena: Black, sticky, tarry, malodorous stool

• Usually from upper GI bleed , above the colon

• 100-200 cc of blood to produce melena

• Digestive enzymes act upon the blood to change the color and consistency

Occult blood. Blood not detectable with naked eye and requires a special test to confirm its presence.