SEMINAR ON

GASTROINTESTINAL
BLEEDNIG

PRESENTERS: MODERATOR:
1. ENDESHAW SIMENEH (c1) DR.FITSUM GETAHUN(MD):
2. FIKREAB KEFALE (c1)
ASSISTANT PROFESSOR OF
INTERNAL MEDICINE
OUTLINE

• Definition
• Epidemiology
• Classification
• Basic terms
• Complications
• Patient approach
• Investigations
• Risk stratification
• Management
 DEFINITION

 Loss of blood anywhere in the gastrointestinal tract

from the pharynx to the rectum.

 GIB presents as either overt or occult bleeding.

EPIDEMIOLOGY

• UGIB incidence: 100 cases/100,000/year

• Mortality is <3% in the USA and around 10% in Europe.

• Mortality increases with older age (>60 yr), in both males and
females.

• Male>Female (2X); mortality is similar

CLASSIFICATION

1. Based on location:
Upper GI bleeding
Lower GI bleeding
Obscure GI bleeding

2. based on duration:
Acute
Chronic
UPPER GI BLEEDING

• Is a bleeding which originates above the ligament of treitz.

• Twice common in male as in females and also Incidence
increases with age.
• Usually present with hematemesis and melena.
• small portion present with hematochezia.
• Upper GI bleeds are considered medical emergencies, and
require admission to hospital for urgent diagnosis and
management.
 CLASSIFICATION OF UGIB

 Non Variceal Bleed Variceal Bleed 6%-39%

• Peptic ulcer disease 31%-67% Gastro-esophageal varices >90%.
 Mallory-Weiss tears 2%-8% Portal hypertensive gastropathy
 Gastritis or duodenitis 2%-18% Isolated gastric varices
 Erosive esophagitis 1%-13%
 Vascular ectasias 0-6%
 Tumors 2%-8%
 Others 5%
 VARICEAL BLEEDING

• Bleeding related to portal hypertension.

• Dilated submucosal veins develop in response to the portal hypertension,

providing a collateral pathway for decompression of the portal system.

• They are most common in the distal esophagus and can reach sizes of 1 to 2
cm.

• As they enlarge, the overlying mucosa becomes increasingly tenuous,

excoriating with minimal trauma and cause severe hemorrhage. .
CONT…

• Correlation to the severity of liver disease:

• Child–Pugh A patients: 40% have varices
• Child–Pugh C patients: 85% have varices

• Some patients may develop varices and hemorrhage early in the

course of the disease, even in the absence of cirrhosis.
• Gastroesophageal varices are present in approximately 50% of
patients with cirrhosis.
• Patients without varices develop them at a rate of 8% per year.
• Patients with small varices develop large varices at a rate of 8%
per year.
 ESOPHAGEAL VARICES

• Up to 25% of patients with newly diagnosed varices will bleed within two
years.

• The risk of bleeding in patients with varices:-

• less than 5 mm in diameter is 7% by two years.
• greater than 5 mm in diameter is 30% by two years.
• The risk of death with variceal bleeding is 20-30% at the first episode
and increases with subsequent episodes.
• The risk of re-bleeding is high, reaching 80% within 1 year.
• Modified Paquet classification used to grade the varices based on the
appearance and luminal diameter.
GRADING OF ESOPHAGEAL
VARICES

Grade I: Small
• Dilated veins (< 5mm) still at the level of
the surrounding tissue.

Grade 2: Medium
• Dilated, straight veins protruding into the
esophageal lumen but not obstructing it.
• Tortuous veins occupying < 1/3 of
esophageal lumen.
CONT…

Grade 3: large
• Large (>5mm) tense and winding veins
already obstructing the esophageal
lumen considerably.
• Occupying > 1/3 of esophageal lumen.

Grade 4:
• Near complete obstruction of the
esophageal lumen
• Impending danger of hemorrhage (cherry
red spots)
PORTAL HYPERTENSIVE GASTROPATHY(PHG)

• is associated to Portal hypertension.

• most commonly develops in the setting of chronic liver injury

with cirrhosis.

• typically is the result of a combination of an increase in

resistance to portal blood flow and an increase in portal blood
flow.
 CONT…

• PHG may be related to both congestion and hyperemia in the stomach.

• This is supported by the finding that gastric mucosal blood flow is increased
in patients with cirrhosis and PHG compared with those without PHG.
• Other possible mechanisms:

mucosal ischemia and increased nitric oxide synthase activity or

inflammation associated with abnormal blood flow due to portal
hypertension.
• The severity of gastropathy is related to portal pressure, the level of hepatic
vascular resistance, and the degree of reduction in hepatic perfusion.
 NON - VARICEAL BLEEDING

Duodenal causes: Other rare cases:

• Esophageal causes: Gastric
Idiopathic angiomas
Duodenal ulcer Osler-Weber-Rendu
Esophagitis causes: syndrome
aorto-enteric fistulae
Radiation-induced
Gastric ulcer Hematobilia
Esophageal ulcers telangiectasia
Gastric cancer Hemosuccus Traumatic or post-surgical
Foreign body ingestion
Esophageal cancerGastritis pancreaticus Post-surgical anastamosis
Dieulafoy's lesions Severe SMA syndrome Postpolypectomy
Mallory-Weiss tear
Gastric antral
 PEPTIC ULCER DISEASE

• Most frequent cause of upper GI hemorrhage, accounting for

approximately 31- 67% of all cases.

• PUD can be classified as Gastric ulcers and Duodenal Ulcer.

• Approximately 10% to 15% of patients with PUD develop bleeding at

some point in the course of their disease.
 CONT…

• Common causes of PUD(95%)

• H. Pylori -associated
• NSAID-associated
• Stress
• Alcoholism, acid
• Uncommon causes of PUD (5%)
• Acid hypersecretion : ZES – mastocytosis
• Other infections: HSV type 1, CMV
• Duodenal obstruction: bands-annular pancreas
• Radiation-induced lesions
• Chemotherapy-induced lesions
• Idiopathic
 MALLORY WEISS TEAR

• Accounts for 2-40% of UGIB hospitalizations

• Classical history is vomiting, retching, or coughing preceding

hematemesis/esp.in alcoholic Pts.

• Bleeding from these tears are usually on the gastric side of gastro esophageal
junction

• Stops spontaneously in 80-90% of pts and reccurs in 10% of pts

LOWER GI BLEEDING

 Bleeding from GIT distal to the ligament of Treitz.

 Common causes:
• Diverticulosis (5-42%)
• Ischemia (6-18%)
• Anorectal (hemorrhoids, anal fissure, rectal ulcers)(6-16%)
• Neoplasms(polyp and cancer) (3-11%)
• Angiodysplasia (0-3%)
• other colitis ( 3-29% )
• inflammatory bowel disesase ( 2-4%)
DIVERTICULAR BLEEDING

• Abrupt onset, painless, sometimes massive often from right

colon & stops spontaneusly in 80-90% patients.

• mild abdominal cramping due to the intra-luminal blood that

triggers spasmodic contraction of the colonic wall.
• acute bleeding, without antecedent symptoms.
• Rebleeding -- 25% of patients.
• If the bleeding is brisk and voluminous, patients may be
hypotensive and display signs of shock.
CONT…

• Chronic, intermittent, minimal blood loss per rectum is unlikely

to be caused by diverticular bleeding, because diverticular
bleeding is arterial in origin.

• Diverticulosis occurs at point where nutrient artery(vasa recti)

penetrate through muscularis propria.
ULCERATIVE COLITIS

The clinical presentation depends on whether it is mild, moderate, or severe.

• Mild disease-minimal to none bleeding

• Moderate-to-severe ---present with bloody diarrhea with pus, abdominal
cramps, and dehydration.
• Severe ---- Symptoms of weight loss and fever occur.

• Patients with Crohn disease usually present with fever, nonbloody

diarrhea, and abdominal pain. However, patients with Crohn colitis can
present with bloody diarrhea.
OBSCURE GIB/SMALL INTESTINE SOURCE

• Obscure GIB is defined as persistent or recurrent bleeding for

which no source has been identified.

• Account for 5% of the pts with GI bleeding.

• Approximately 75% of it is from small bowel.

• Patients without a source of GIB identified on upper endoscopy

and colonoscopy were previously labeled as having obscure GIB.
CONT…

Most common causes:

Age >40 Age <40
Vascular ectasias Crohn’s disease
Neoplasms Polyps
Erosions Neoplasms
 ACUTE VS CHRONIC GIB

 ACUTE  CHRONIC
• All cases with a recent (i.e. within
Bleeding for several days.
48 hours) significant GI bleeding .
• Brief and severe. Usually present with iron-deficiency anemia.
• Symptoms of acute GI bleeding:
Symptoms of chronic bleeding include:
crampy abdominal Fatigue, shortness of breath
pain Pallor, chest pain, dizziness, lethargy
faintness, confusion Faintness, black or tarry stool
Bright red blood /Coffee-ground
disorientation appearance of vomit
sleepiness
BASIC TERMS

• Hematemesis:
• Vomiting of fresh or old blood and indicates an UGIB source.
• Bright red blood = Significant bleeding
• Coffee ground emesis = no active bleeding

• Melena:
• Passage of black & foul smelling stool and indicates blood has
been present in the GI tract for ≥14 h, and as long as 3–5 days.
• The more proximal the bleeding site, the more likely melena will
occur.
CONT…

• Hematochezia:
• Passage of bright red/ maroon colored blood per rectum.
• If brisk & significant could be UGI source.
• When hematochezia is the presenting symptom of UGIB, it is
associated with hemodynamic instability and dropping hemoglobin.

• Occult bleeding:
• Bleeding not apparent to the patient but fecal occult blood test is
+ve.
• May lead to dyspnea & even MI
 HEMATEMESIS VS HEMOPTYSIS

HEMATEMESIS HEMOPTYSIS
RESPIRATORY TRACT
GI TRACT
Bright red
Dark red or brown
Foamy, runny
In clumps

Mixed with food Mixed with mucous

Acidic pH Alkaline pH

Stomachache, abdominal discomfort Nausea, Chest pain, warmth or gurgling over the chest
retching before and after episode Persistent cough
COMPLICATIONS

• Anemia
• Shock
• Acute kidney injury
• Hypovolemia
• Complications related to blood transfusions, such as acquired
infections or transfusion reaction.
• Complications related to procedural interventions, such as
perforation and infection.
APPROACH TO A PATIENT WITH GASTROINTESTINAL BLEEDING

• INITIAL ASSESSMENT
assess hemodynamic status
resuscitation
• DIFFERENTIATION OF UGIB FROM LGIB
UGIB source:
Hematemesis, Melena
Hyperactive bowel sounds and
Elevated blood urea nitrogen
CONT…

• Lower GI source:
Hematochezia

• Nasogastric lavage
EVALUATION AND MANAGEMENT OF A PATIENT WITH UGIB

INITIAL EVALUATION

Includes:
• history
• physical examination
• laboratory tests, and in some cases, nasogastric
lavage.
CONT…

The goal of evaluation is:

• to assess the severity of the bleed.
• identify potential sources of the bleed.
• determine if there are conditions that may affect
subsequent management.
• to guide decisions regarding triage, resuscitation,
empiric medical therapy, and diagnostic testing.
HISTORY

Manifestations:
Hematemesis (either red blood or coffee-ground
emesis)
Melena (black, tarry, offensive stool)
Hematochezia (red or maroon blood in the stool)
 CONT…

Past medical history:

Prior episodes of upper GI bleeding
Comorbid conditions:
1. Cause upper GI bleeding: liver disease, history of H. pylori infection
: renal disease, aortic stenosis
2. May influence the patient's subsequent management:
coronary artery disease, pulmonary disease
renal disease, heart failure, coagulopathies
CONT…

Medication history:
A thorough medication history should be obtained, with
particular attention paid to drugs that:
Predispose to peptic ulcer formation
Are associated with pill esophagitis
Promote bleeding
May alter the clinical presentation.
CONT…

Symptom assessment
1. To anticipate the severity of the bleed
Symptoms that suggest the bleeding is severe include:
orthostatic dizziness
confusion
angina, severe palpitations, and
cold/clammy extremities.
CONT…

2. To identify the potential source of bleeding

Peptic ulcer: Epigastric or right upper quadrant pain
Esophageal ulcer: Odynophagia, gastroesophageal reflux,
dysphagia
Mallory-Weiss tear: Emesis, retching, or coughing prior to
hematemesis
Variceal hemorrhage: Jaundice, weakness, fatigue,
anorexia, abdominal distention
Malignancy: Dysphagia, early satiety, involuntary weight
loss, cachexia
PHYSICAL EXAMINATION

• physical examination is a key component of the assessment

of hemodynamic stability.
General appearance:
acutely sick/acute on chronic base(active bleeding with
blood soaked cloth)
altered mental status
malnourished
in distress
CONT…

• Vital signs
blood pressure: orthostatic/supine hypotension
pulse rate: resting tachycardia
respiratory rate: tachypnea
temprature: fever
oxygen saturation: decreased
weight: decreased
CONT…

• H.E.E.N.T:
pale conjunctiva, icteric sclera
epistaxis, dry buccal mucosa, gum bleeding

• Lymphoglandular system
parotid enlargement
breast enlargement
testicular atrophy
CONT…

• Respiratory system

clubbing, signs of distress, dullness, crackles

• CVS: S3 gallop, systolic murmur

• Abdomen: abdominal distension with flank fullness, distended vein

epigastric tenderness, rebound tenderness, splenomegaly,

hepatomegaly
shifting dullness, fluid thrill
hyperactive bowel sound
per rectal exam: melenic stool
 CONT…

MSS:
Dupuytren's contracture

IS:
cold extremities, slow capillary refill, pallor
palmar erythema, spider angioma
purpura, echymoses, petechiae
Loss of hair
CNS:
altered mentation, asterixis
LABORATORY TESTS

• CBC, blood group, Rh

• Serum chemistries: BUN, creatinine
• Liver function tests, liver enzymes, coagulation studies.
• H.pylori testing
• Cardiac enzymes
NASOGASTRIC LAVAGE

• used when it is unclear if a patient has ongoing bleeding and

thus might benefit from an early endoscopy.

• to facilitate endoscopy.

• the presence of red blood or coffee ground material in the

aspirate also confirms an upper GI source of bleeding.
DIAGNOSTIC STUDIES

• Upper endoscopy:
is the diagnostic modality of choice for acute upper GI
bleeding.
serves both diagnostic and therapeutic purpose.

• Angiography and a tagged red blood cell scan

• Serial electrocardiogram
 RISK STRATIFICATION

• Helps to:
identify patients at high risk for adverse outcomes
determine patient disposition(outpatient, inpatient, ICU)
determine appropriate timing of endoscopy
• Endoscopic, clinical, and laboratory features are used for risk
stratification.
• Risk scores:
Two commonly cited scoring systems are: Rockall score and Blatchford
score
 CONT…

• Three groups based on the parameter used:

ENDOSCOPY ONLY:
Forrest classification
CLINICAL AND ENDOSCOPY:
- Rockall score (commonly used and Max 11)
- Baylor Bleeding Score (BBS)
CONT…

CLINICAL AND LABORATORY:

The Glasgow-Blatchford Score (GBS)
AIMS65: has high accuracy for predicting inpatient
mortality
The T-score
 FORREST CLASSIFICATION

Forrest Ia, Ib and IIa lesions require endoscopic treatment. For the ulcers with adherent clots (Forrest IIb) clot removal should be
attempted by vigorous irrigation and should be treated according to the underlying lesion.
 THE ROCKALL SCORE

Ranges from 0 to 11.

Developed to predict mortality due to UGIB.
• Has five variables:
Age
Haemodynamic status
Comorbidities
Endoscopic diagnosis and
Presence of major stigmata of recent haemorrhage
• Score of greater than 2 suggests high risk for recurrent bleeding and
death.
CONT…
GLASGOW BLATCHFORD SCORE

 Used to identify patients with acute UGIB who need clinical intervention.
 Incorporates 8 variables
• heart rate AGE HIGH RISK
• haemoglobin value <70 score >2
• blood urea nitrogen >70 score >1
• systolic blood pressure
• melena occurrence
• syncope
• hepatic disease
• heart failure
CONT…

The GBS ranges from 0 to 23,

with higher scores indicating
likelihood of a need for an
endoscopic intervention.

1,2 Known history or

clinical and laboratory evidence
OTHERS
MANAGEMENT

• GENERAL MANAGEMENT

ABC of life
Triage: All patients with hemodynamic instability or
active bleeding should be admitted to an ICU for
resuscitation and close observation with:
automated blood pressure monitoring
electrocardiogram monitoring, and
pulse oximetry.
CONT…

• General support:
Supplemental oxygen by nasal cannula and should receive NPO
Venous line should be inserted
Placement of a pulmonary artery catheter
Elective endotracheal intubation
• Fluid resuscitation
CONT…

• Blood transfusion

Initiate blood transfusion if:

The hemoglobin is <7 g/dL for patients who do not have significant comorbid
illnesses.
The hemoglobin is <9 g/dL for patients with unstable coronary artery disease.
It is important to avoid overtransfusion in patients with suspected variceal
bleeding.

• Frozen plasma (FFP) or platelets.

DEFINITIVE MANAGEMENT

• Medications
Acid suppression:
proton pump inhibitor (PPI).
Prokinetics:
To improve gastric visualization at the time of endoscopy by
clearing the stomach of blood, clots, and food residue.
CONT…

• Somatostatin and its analogs:

used in the treatment of variceal bleeding
• Antibiotics for patients with cirrhosis:
ceftriaxone, quinolones
• Endoscopic management
SUGGESTED ALGORITHM FOR PATIENTS WITH ACUTE UPPER
GASTROINTESTINAL BLEEDING BASED ON ENDOSCOPIC FINDINGS
FAILURE OF THERAPY

Defined by any of the following criteria:

• Fresh hematemesis or >100 ml of blood in the naso-gastric
aspirate more than 2 hrs after initiation of a specific drug or
endoscopic treatment.
• Development of hypovolemic shock.
• Drop in hemoglobin of ≥3 gm within a 24 hour period.
EVALUATION AND MANAGEMENT OF A PATIENT WITH LGIB

History: hematochezia
comorbidities
medications
prior history of bleeding
family history of colon cancer
history of abdominal surgery
Physical examination: assess the hemodynamic status
inspect for hemorrhoids and anal fissure
per rectal exam: blood, mass
CONT…

• Laboratory tests
CBC, blood group, Rh
BUN, Cr
• Nasogastric lavage

• Fecal occult blood test

CONT…

• Imaging studies
Colonoscopy Push enteroscopy
Angiography Capsule endoscopy
CT angiography Deep small bowel
enteroscopy
Radionuclide imaging
MANAGEMENT

• ABC of life
Resuscitation

• Triage:
high risk patients at high ICU level

• Definitive mgt
SUGGESTED ALGORITHM FOR PATIENTS WITH ACUTE LOWER
GASTROINTESTINAL BLEEDING
REFERENCES

• Harrison 20th edition

• Upto date 21.6
THANK YOU!