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.
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.