GI Bleeding:
From Mouth to Rectum and Everywhere in Between
Outline
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Epidemiology and Risk Factors
Signs and Symptoms
Physical Exam Findings
Etiologies
Diagnosis
Management
Will focus
mostly on
inpatients
Epidemiology
Key Point: Mortality LGIB
< UGIB < Variceal bleeds
• Upper GI bleeds (UGIB)
▫ 100,000 admissions/year to US hospitals
▫ 10% mortality
• Variceal bleeds
▫ 30% of identified varices will bleed in 1 year
▫ 33% mortality with each bleed
• Lower GI bleeds (LGIB)
▫ Less common than UGIB
▫ 3% mortality
Key Point:
Risk Factors
Most Important Part of History!
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NSAID Use
Cirrhosis
Anticoagulation/Coagulopathy
Age
Risk factors for colon cancer
Previous history of GI bleeding
Signs and Symptoms
Upper GI Bleed
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Lightheadedness/Syncope
Diarrhea
Anemia
Hematemasis
Melena
Stigmata of cirrhosis
Heartburn
Lower GI Bleed
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Lightheadedness/Syncope
Diarrhea
Anemia
Hematochezia
Physical Exam Findings
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Vital signs (more later)
Dry mucus membranes
Stigmata of cirrhosis
Fetid breath
DRE – gotta do it
Weak pulses
Cool skin
Encephalopathy
Common Etiologies
Upper GI Bleed
Lower GI Bleed
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• Diverticular disease – 30%
• Colitis – 18%
▫ Ischemic
▫ Inflammatory
▫ Infectious
• Neoplasms – 10%
• AVMs – 8%
• Hemorrhoids – 5%
• Others – 20%
PUD – 55 %
Varices – 14 %
AVMs – 6%
Mallory Weiss Tears – 5%
Tumors/Erosions – 4%
Dieulafoy’s lesions – 1%
Others 15%
Khilani et all, Emerg Med 37(10):27-32, 2005
Diagnosis
• Upper or Lower?
▫ History
▫ Digital Rectal Exam
▫ Hemoglobin
• Still bleeding?
▫ Consider NG Lavage
• What’s the etiology?
▫ Diagnostic Testing
Freebees
These can usually make the diagnosis
Diagnostic Testing
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EGD – standard for UGIB
Colonoscopy – standard for LGIB
Push Enteroscopy – can image through SB
Capsule Endoscopy – good yield - can’t
intervene
• Sigmoidoscopy – rarely used
• Barium studies – good to look for lesions/mass
• Tagged red cell scans – poor yield
For more information, do a GI fellowship!
Management – General Principles
• Risk stratify
▫ Assess blood loss
▫ Blatchenford score
Beyond the scope of this discussion!
▫ Rockall score (after EGD)
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IV access
Volume replacement
Acid suppression therapy
Plan for diagnostic procedure
Management: Assess Blood Loss
Categor
y
% loss
HR
BP
Pulse
Pressure
UOP
Stage 1
<15 %
< 100
Normal
Normal
> 30
Stage 2
15-30%
> 100
Normal
Decreased
20-30
Stage 3
30-40% > 120
Decrease
d
Decreased
5-15
Stage
4
> 40%Life >Support
140 Guidelines
Decrease
From
Advanced
Trauma
Decreased
Negligible
d
HR not useful if
patients are on AV
node blockers
Tachycardic means
they have lost about
1 liter of blood!
Key Points
If they are
hypotensive, you
are in trouble!
Management: Access and Volume
• IV Access
▫ Two large bore peripheral IVs is best
• Volume replacement
▫ Normal saline
▫ Blood products
▫ Consider FFT/Cryo/FFP
MGMT: Acid Suppression
• Applies to UGIB from ulcers
Key Point: PPIs can
improve mortality
Gralnek I.M et al. NEJM 2008
MGMT: Acid Suppression (con’t)
• Other questions:
 Continuous versus bolus?
 IV versus oral?
 Duration of treatment?
Management – Suspected Varices
• Initial stabilization
• Splanchnic Vasoconstricters:
Octreotide/Vasopressin
• TIPS
• Minnesota tube/Blakemoore tube
• Antibiotic prophylaxis
• A whole other talk
Key Points
• GI bleeding is a common hospital diagnosis –
Look for it
• Risk factors are the most important part of the
history
• Vital signs can help risk stratify patients
• PPIs can reduce need for surgery, rebleeding,
and death