GI Bleeding

Kayley Josephs

Background

  • Intraluminal blood loss anywhere along digestive tract from nasopharynx/oral cavity to anus.
  • Consider epistaxis and oropharyngeal bleeding as possible sources of melena.
  • Upper GIB (UGIB) = proximal to Ligament of Treitz (LoT). 
    • PUD, gastritis (alcohol, stress, NSAIDs, ASA), esophagitis, varices (cirrhosis), Mallory- Weiss tear, AVM, Dieulafoy’s lesion, aorto-enteric fistula, gastric antral vascular ectasias, malignancy.
  • Lower GIB (LGIB) = distal to LoT. 
    • Diverticulosis, ischemic/infectious/IBD/radiation colitis, malignancy, angiodysplasia, anorectal (hemorrhoids, anal fissure), Meckel’s diverticulum, post-polypectomy bleed.

Historical factors to consider when identifying possible source

  • Cirrhosis or chronic alcohol use: varices or portal hypertensive gastropathy.
  • Hx of AAA or aortic graft: aorto-enteric fistula.
  • Hx of renal disease, aortic stenosis, HHT: angiodysplasia.
  • Hx of H. pylori, NSAID use, tobacco use: PUD.
  • Hx of tobacco use, H. pylori, weight loss, early satiety, dysphagia, change in bowel habits: malignancy.
  • Painless hematochezia: diverticular bleed.
  • Abdominal pain: colitis.
  • Common false positives: bismuth, charcoal, licorice, and iron supplements.

Presentation

  • Hematemesis, hematochezia (usually LGIB although could be brisk UGIB), melena, coffeeground emesis, epigastric/abdominal pain, iron-deficiency anemia.
  • Exam: VITALS – assess hemodynamic stability to determine resuscitation needs (MICU vs. floor), fecal occult blood test, signs of cirrhosis (jaundice, palmar erythema, ascites, spider angiomata).

Evaluation

  • CBC, CMP, PT/INR, Lactate, Blood Gas.
  • BUN/Cr ratio > 30 is more predictive of UGIB; < 20 is more predictive of LGIB.
  • Upper endoscopy +/- colonoscopy.
  • Difficulty localizing GIB: pill-capsule, balloon enteroscopy Meckel’s scan, tagged RBC scan.
  • Massive lower GI bleeds require arteriography.

Management

  • Secure airway (intubation) if comatose, extremely combative, or massive hematemesis.
  • At least 2 large bore IV’s (> 18 gauge) – ask nursing to place.
  • Maintain active type and screen.
  • Bolus IVF to maintain MAP > 65; H/H monitoring q6-q12h; transfuse as indicated.
  • Active bleeding: IV PPI (pantoprazole) 40mg BID if presumed UGIB/ulcer. If no active bleeding, IV PPI 40mg QD.
  • Cirrhosis + UGIB: Ceftriaxone 1g/day (x 5-7d) for SBP prophylaxis.
  • If possibility of variceal bleed: IV Octreotide 50 mcg bolus -> 50 mcg/hr (x 3-5d).
  • NPO if unstable vs. clear liquids (no reds or purples) until midnight before EGD.
  • Balloon tamponade can temporize uncontrolled esophageal variceal hemorrhage (needs to be intubated to place device).
  • For massive LGIB: If hemodynamically unstable, consult IR and obtain CTA abd/pelvis while resuscitating with fluids vs blood. If hemodynamically stable, obtain EGD to rule out UGIB. If source is not identified on EGD, obtain CTA (if actively bleeding) or colonoscopy (if bleeding has stopped). If source is not identified on CTA, investigate for small bowel bleeding.
  • Never order bowel prep for a patient for colonoscopy (GoLytely) without discussing with GI fellow.
  • Consult GI to facilitate endoscopy. Consider consulting hematology if emergent anticoagulant reversal agent is needed.
    • If endoscopy is unable to stop bleeding -> consult IR for embolization.
    • If embolization fails -> consult EGS for source removal.
Last updated on