GASTROINTESTINAL

BLEEDING
Dr Mensah Amoah

BSc. Med Science/MBChB/MWACP/MGCPS

Outline
• Clinical case
• Review Questions
• Definitions
• Principles of Management of GI Bleeding

• Epidemiology and Aetiology of Upper GI Bleeding

• Resuscitation in Upper GI Bleeding

• Evaluation of Upper GI Bleeding

• Lower GI Bleeding
• Answer Review Questions
 CLINICAL CASE
• A 45 year old man presented to the emergency room with hematemesis.
Prior to this he had had 1 month history of intermittent malena stools.
Relatives claimed he takes 32 units of alcohol per week for the past 15
years. On examination GCS was 10/15, BP-85/55mmHg and pulse of
120bpm, weak and thready. He was jaundiced, had ascites and had pedal
swelling. JVP was not raised and chest was clear.
Concerning this patient
A. Explain what is going on with this patient?
B. How will you manage this patient in the emergency room?
C. Mention relevant investigations
D. What emergency medications can be used for this patient?
Q1. A 52 year old man presented with hematochezia and hypotension.
He takes 42 units of alcohol per week for the past 10years. On
examination GCS-10/15, BP-80/40 and Pulse -118bpm, weak volume. He
was jaundiced and shifting dullness was positive. All of the following are
true except

• A. Full blood count may show high MCV and low platelet counts
• B. Liver size maybe normal on clinical examination
• C. Bleeding peptic ulcer is a differential diagnosis
• D. It’s unlikely an upper GI bleeding since he’s having hematochezia
• E. Bleeding esophageal varices is the most likely diagnosis
Q2. Concerning the patient above in Q1 which is not True

• A. Propranolol can be used when patient is stable

• B. Octreotide can reduce ongoing bleeding
• C. Intravenous fluids and Blood transfusion is the most effective initial
management
• D. Sengstaken-Blakemore tube can be used in uncontrollable bleeding in
this patient
• E. Patient should be rushed for emergency endoscopy immediately to
stop bleeding
Q3 The following are features of Portal hypertension except
• A. Ascites
• B. Esophageal Varices
• C. Splenomegaly
• D. Thrombocytosis
• E. Thrombocytopenia
Q4. The following are endoscopic treatment options in a non-variceal
upper gastrointestinal bleeding except
A. Thermal Electrocoagulation
B. Hemoclips
C. Beta Blocker Injection
D. Epinephrin Injection
E. Under running of Bleeding vessel
Q5. Which of these is true concerning emergency management of
bleeding peptic ulcer
A. Early use of propranolol improves prognosis
B. Intravenous antibiotics prevents hepatic encephalopathy
C. Endoscopy must be done within 24hrs especially when patient is
unstable in order to stop the bleeding
D. Early use of intravenous PPIs may reduce bleeding
E. Endoscopic treatment options include epinephrine injection and
variceal banding
Q6 Concerning Variceal Bleeding, one of these is not true
• A. Intravenous octreotide will reduce the systemic blood pressure in
order to reduce the portal pressure
• B. Sudden collapse and death could be a presentation
• C. Proton pump inhibitor may be used prior to endoscopy
• D. Prophylactic antibiotics reduce risks of hepatic encephalopathy and
rebleeding
• E. Aggressive expansion of plasma volume from fluid resuscitation
may worsen bleeding
Q7. A 35 year old man with no history of alcohol intake was admitted with
right hypochondriac pains and jaundice of 2 months duration. His elder
brother and younger sister have been diagnosed with hepatitis B infection. On
examination he was cachectic with moderate anaemia, tender nodular liver in
the right hypochondriac region with ascites and malena stools on DRE. Full
blood count showed HB 7.9g/dl, platelet count of 98. Which of the following
is the false
• A. He certainly has portal hypertension
• B. Hepatocellular carcinoma from Hepatitis B infection is likely diagnosis
• C. His MCV may be low or high
• D. If patient does not have splenomegaly, a diagnosis of portal hypertension
cannot be made
• E. INR or PT may be elevated.
GI BLEEDING
Definitions
Gastrointestinal bleeding comprises
upper and lower gastrointestinal


bleeding
– Difference is defined by location of
source of bleeding
– Either proximal or distal to the ligament
of Treitz ( duodenal suspensory
ligament that attaches at the junction of
duodenum and jejunum)
 Definitions
• Acute –Sudden onset of large volume gastrointestinal bleeding, may result
in hypovolemic shock

• Chronic /Occult-low volume, gradual onset and progressive GI bleeding

which may lead to chronic anemia, stool occult blood positive, no
information on localization

• Malena Stools
-Dark, tarry pungent stools
-Usually suggestive of UGI origin-90% (but can be small intestinal,
proximal colon origin if slow pace)
Definitions
• Hematochezia
– Spectrum: bright red blood, dark red, maroon
– Usually suggestive of colonic origin (but can be UGI origin if brisk
pace/large volume-10%)
Principles of Management of Gastrointestinal
Bleeding
• Assess severity of bleeding and Need for Immediate Resuscitation

• Detailed History and Examination

• Investigation of Underlying cause of GI Bleeding

• Treatment of Underlying cause of GI Bleeding

GI BLEEDING
Epidemiology
:
 Upper: Lower GI bleeding = 5:1
 Incidence: 50-100 per 100,000 pts.
100 per 100,000 hospital admission.
 30% pts are older than 65 years.
80% are self-limited.
20% of pts who have recurrent
bleeding (within 48-72 hrs) have poor
prognosis.
 Most deaths caused by GI bleeding occur
in patients older than age 60 years
 UGIB is more common in men than
women (2:1), whereas LGIB is more
common in women
 Significant UGIB requiring admission is
more common in adults, whereas LGIB
requiring admission is more common in
children
 Upper GI Bleeding (UGIB)
• Acute gastrointestinal bleeding is a potentially life-threatening abdominal
emergency that remains a common cause of hospitalization.

• Categorized as either variceal or non-variceal. Variceal is a complication of

portal hypertension which may be due to cirrhosis of the liver

• Non variceal bleeding associated with peptic ulcer disease or other causes of
UGIB.

• UGIB is 4 times as common as bleeding from lower GIT, with a higher

incidence in male.
 Upper GI Bleeding - Epidemiology

 Incidence 150/100,000 population per year.

 Overall mortality 10% in those admitted to hospital.
 Mortality 30 % in the elderly.
 1 in 1000 in us who experienced upper GI bleeding
Men :women 2:1
 50% present with hematemesis
 11% of brisk bleeds have hematochezia
 Melena (black tarry stools)—this develops with
apporximately 150-200cc of blood in the upper GI
tract.Stool turns black after 8 hours of sitting within the
gut.
 Comparison
Site of bleeding Recurrence of Mortality rate
bleeding % %
PU 3-8
10-32
20-30
Varices
42-70 3-4

Mallory-Weiss 9-13 tear

  Esophageal causes:

 Esophageal varices
 Esophagitis
 Esophageal cancer
aetiology  Esophageal ulcers
 Mallory-Weiss tear

Gastric causes:


 Gastric ulcer
 Gastric cancer
 Gastritis
 Gastric varices
 Dieulafoy's
  Duodenal causes:
 Duodenal ulcer

aetiology  Vascular malformation including

aorto-enteric fistulae
 Hematobilia, or bleeding from the
biliary tree
 Hemosuccus pancreaticus, or
bleeding from the pancreatic
duct
 Severe superior mesenteric
artery syndrome
Upper GI Bleeding – Common Causes

 Doudenal
Ulcer

Doudenal Ulcer Bleeding doudenal

ulcer
Upper GI Bleeding – Common Causes

 Gastric
Ulcer

Gastric Bleeding gastric ulcers

ulcer
Upper GI Bleeding – Common Causes

 Esophageal Varices

Esophageal Bleeding esophageal varices

Varices
Upper GI Bleeding – Common Causes

Gastric varices Mallory Weiss Tear Esophagitis

Upper GI Bleeding – rare causes

 Angiodysplasia of the stomach

GI
Malignancy
 Esophageal • Gastric Carcinoma
Tumo
r
Duodenal
Ulcer
 Clinical Presentation
• Hematemesis - 40-50% • Dyspepsia - 18%
• Melena - 70-80% • Epigastric pain - 41%
• Hematochezia - 15-20% • Heartburn - 21%
• Either hematochezia or melena - • Diffuse abdominal pain - 10%
90-98% • Dysphagia - 5%
• Syncope - 14.4% • Weight loss - 12%
• Presyncope - 43.2% • Jaundice - 5.2%
Physical Examination
• Pulse
• Blood Pressure
• Consciousness level
• Urine output
• CVP/JVP
• Signs of underlying cause of UGIB-Signs of Chronic liver disease in
variceal bleeding, etc
Initial Assessment
• Always remember to assess A,B,C’s
• Assess degree of hypovolemic shock
Class I Class II Class III Class IV
Blood loss (mL) 750 750-1500 1500-2000 >2000

Blood volume < 15% 15-30% 30-40% >40%

loss (%)

Heart rate <100 >100 >120 >140

SBP No change Orthostatic Reduced Very low, supine
change
Urine output >30 20-30 10-20 <10
(mL/hr)
Mental status Alert Anxious Aggressive/ Confused/
drowsy unconscious
 Resuscitation
• IV access: large bore peripheral IVs best, FBC, GXM and transfuse if Hb <7g/dl

• Use crystalloids first-Normal saline/ringers lactate, can use colloids if need be!

• Anticipate need for blood transfusion

• Threshold should be based on underlying condition, hemodynamic
status, markers of tissue hypoxia
• Should be administered if Hgb ≤ 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT by 3%)
• Remember that initial Hct can be misleading (Hct remains the same
with loss of whole blood, until re-equilibration occurs)
• Correct coagulopathy
Resuscitation
• IV access: large bore peripheral IVs best (alt: cordis catheter)
• Use crystalloids first bleed Time
• Anticipate need for blood transfusionIVFs
40%
• Threshold should be based on underlying
40% condition,20%
hemodynamic status,
markers of tissue hypoxia
• Should be administered if Hgb ≤ 7 g/dL
• 1 U PRBC should raise Hgb by 1 (HCT by 3%)
• Remember that initial Hct can be misleading (Hct remains the same with loss of
whole blood, until re-equilibration occurs)
• Correct coagulopathy
Transfusion Strategy
• Randomized trial:
• 921 subjects with severe acute UGIB
• Restrictive (tx when Hgb<7; target 7-9) vs. Liberal (tx when Hgb<9; target 9-
11)
• Primary outcome: all cause mortality rate within 45 days

NEJM 2013;368;11-21
Restrictive Strategy Superior
Restrictive Liberal P value
Mortality rate 5% 9% 0.02
Rate of further 10% 16% 0.01
bleeding
Overall 40% 48% 0.02
complication
rate

NEJM 2013;368;11-21
Resuscitation
• IV access: large bore peripheral IVs best (alt: cordis catheter)
Weigh risks and benefits of
• Use crystalloids first reversing anticoagulation

• Anticipate need for blood transfusion Assess degree of coagulopathy

• Threshold should be based on underlying condition, hemodynamic status,
markers of tissue hypoxia Vitamin K – slow acting, long-
• Should be administered if Hgb ≤ 7 g/dL lived
• 1 U PRBC should raise Hgb by 1 (HCT by 3%)
FFP – fast acting, short lived
• Remember that initial Hct can be misleading (Hct remains
- Give 1 U FFPthe same4 with
for every U loss of
whole blood, until re-equilibration occurs) PRBCs
• Correct coagulopathy
 Emergency Medications
• PPI-Intravenous administration-stabilize clots and reduce bleeding in 70% of
cases due to PUD

• Colloids-Haemacel/hetarstarsch

• Inotropes-Somatostatine Analogues (octreotide/lanreotide –In variceal

bleeding may help with reduction in portal pressure and reduced bleeding
-Noradrenaline/Dopamine/Dobutamine

• Devices- Sengstaken–Blakemore tube/Minnesota tube (Esophageal Varices)

Sengstaken–Blakemore tube/Minnesota tube
Emergency UGI endoscopy
• Done when patient is clinically stable
Endoscopy - Nonvariceal UGIB
• Early endoscopy (within 24 hours) is recommended
for most patients with acute UGIB
• Achieves prompt diagnosis, provides risk stratification
and hemostasis therapy in high-risk patients

J Clin Gastroenterol 1996;22:267

Gastrointest Endosc 1999;49:145
Ann Intern Med 2010;152:101
Pre-endoscopic Pharmacotherapy
• For Non-Variceal UGIB
• IV PPI: 80 mg bolus, 8 mg/hr drip
• Rationale: suppress acid, facilitate clot formation and
stabilization
• Duration: at least until EGD, then based on findings
 When is Endoscopic Therapy
Required?
• ~80% bleeds spontaneously resolve
• Endoscopic stigmata of recent hemorrhage
Stigmata Continued/rebleeding rate

Active bleeding 55-90%

Major
Non bleeding visible vessel 40-50%

Adherent clot Variable, depending on underlying

lesion: 0-35%

Flat pigmented spot 7-10%

Clean base < 5%

Major Stigmata – Active Spurting

Kelsey, PB (Dec 04 2003). Duodenum - Ulcer, Arterial Spurting, Treated with Injection
and Clip. The DAVE Project. Retrieved Aug, 1, 2010, from
http://daveproject.org/viewfilms.cfm?film_id=39
Major Stigmata - NBVV
Adherent Clot
• Role of endoscopic therapy of
ulcers with adherent clot is
controversial
• Clot removal usually attempted
• Underlying lesion can then be
assessed, treated if necessary
Minor Stigmata

Flat pigmented spot Clean base

Low rebleeding risk – no endoscopic therapy

needed
Endoscopic Hemostasis Therapy
• Epinephrine injection
• Thermal electrocoagulation
• Mechanical (hemoclips)

• Combination therapy
superior to monotherapy

Kelsey, PB (Nov 08 2005). Stomach - Gastric Ulcer, Visible Vessel. The DAVE Project.
Retrieved Aug, 1, 2010, from http://daveproject.org/viewfilms.cfm?film_id=306

Baron, TH (May 01 2007). Duodenum - Bleeding Ulcer Treated with Thermal Therapy,
Perforation Closed with Hemoclips. The DAVE Project. Retrieved Aug, 1, 2010, from
http://daveproject.org/viewfilms.cfm?film_id=620
Nonvariceal UGIB –
Post-endoscopy management
• Patients with low risk ulcers can be fed promptly, put
on oral PPI therapy.
• Patients with ulcers requiring endoscopic therapy
should receive PPI gtt x 72 hours
• Significantly reduces 30 day rebleeding rate vs placebo
(6.7% vs. 22.5%)
• Note: there may not be major advantage with high dose
over non-high dose PPI therapy

N Engl J Med 2000;343:310

Arch Intern Med 2010;170:751
Nonvariceal UGIB –
Post-endoscopy management
• Determine H. pylori status in all ulcer patients
• Discharge patients on PPI (once to twice daily),
duration dictated by underlying etiology and need for
NSAIDs/aspirin
• In patients with cardiovascular disease on low dose
aspirin: restart as soon as bleeding has resolved
– RCT demonstrates increased risk of rebleeding (10% v 5%)
but decreased 30 day mortality (1.3% v 13%)

Ann Intern Med 2010;152:1

Nonvariceal UGIB –
Post-endoscopy management
• Determine H. pylori status in all ulcer patients
• Discharge patients on PPI (once to twice daily),
duration dictated by underlying etiology and need for
NSAIDs/aspirin
Not dying is more important
• In patients with cardiovascular disease on low dose
than not rebleeding
aspirin: restart as soon as bleeding has resolved
– RCT demonstrates increased risk of rebleeding (10% v 5%)
but decreased 30 day mortality (1.3% v 13%)

Ann Intern Med 2010;152:1

 Variceal Bleeding
• Occurs in 1/3 of patients with cirrhosis
• 1/3 initial bleeding episodes are fatal
• Among survivors, 1/3 will rebleed within 6 weeks
• Only 1/3 will survive
1 year or more
Predictors of large esophageal varices
• Severity of liver disease (Child Pugh)
• Platelet count < 88K
• Palpable spleen
• Platelet count/spleen diameter (mm) ratio <909

Gut 2003;52:1200
J Clin Gastroenterol 2010;44:146
J Gastroenterol Hepatol 2007;22:1909
Arch Intern Med 2001;161:2564
Am J Gastroenterol 1999;94:3103
 VARICEAL Bleed

• Vasoconstrictor therapy
• Antibiotics
• Resuscitation
• ICU level care
• Endoscopy
• ALternative/Rescue therapies
• Beta blockade
Vasoconstrictor therapy
• Goal: Reduce splanchnic blood flow
• Terlipressin – only agent shown to improve control of
bleeding and survival in RCTs and meta-analysis
• Vasopressin + nitroglycerine – too many adverse effects
• Somatostatin
• Octreotide (somatostatin analogue)
• Decreases splanchnic blood flow (variably)
• Efficacy is controversial; no proven mortality benefit
• Standard dose: 50 mcg bolus, then 50 mcg/hr drip for 3-5 days

Gastroenterology 2001;120:946
Cochrane Database Syst Rev 2008;16:CD000193
N Engl J Med 1995;333:555
Am J Gastroenterol 2009;104:617
 Antibiotics

• Bacterial infection occurs in up to 66% of patients with cirrhosis and

variceal bleed
• Negative impact on hemostasis (endogenous heparinoids)
• Prophylactic antibiotics reduces incidence of bacterial infection,
significantly reduces early rebleeding
– Ceftriaxone 1 g IV QD x 5-7 days
– Alt: Norfloxacin 400 mg po BID

Hepatology 2004;39:746
J Korean Med Sci 2006;21:883
Hepatogastroenterology 2004;51:541
 Resuscitation

• Promptly but with caution

• Goal = maintain hemodynamic stability, Hgb ~7-8, CVP 4-8 mmHg
• Avoid excessively rapid over-expansion of volume; may increase
portal pressure, greater rebleeding
Endoscopy

• Should be performed as
soon as possible after
resuscitation (within 12
hours)
• Endotracheal intubation
frequently needed
• Band ligation is preferred
method

Layer, L. & Jaganmohan, S. & Raju, GS & DuPont, AW (Oct 28 2009). Esophagus - Band
Ligation of Actively Bleeding Gastroesophageal Varices. The DAVE Project. Retrieved
Aug, 2, 2010, from http://daveproject.org/viewfilms.cfm?film_id=715
ALternative/Rescue therapies
• TIPS – Transjugular Intrahepatic
Portosystemic Shunt
• Early placement of shunt
(within 24-72hrs) associated
with improved survival among
high-risk patients
• Preferred treatment for gastric
variceal bleeding (rule out
splenic vein thrombosis first)

Fan, C. (Apr 25 2006). Vascular Interventions in the

Abdomen: New Devices and Applications. The DAVE
Project. Retrieved Aug, 2, 2010, from
Hepatology 2004;40:793 http://daveproject.org/viewfilms.cfm?film_id=497
Hepatology 2008;48:Suppl:373A
N Engl J Med. 2010 Jun 24;362:2370
 ALternative/Rescue therapies

• Very effective for

Sengstaken-Blakemore Tube
immediate, temporary
control
• High complication rate –
aspiration, migration,
necrosis + perforation of
esophagus
• Use as bridge to TIPS within
24 hours
• Airway protection strongly
recommended
 Beta blockade

• Reduces risk for recurrent variceal hemorrhage

• Use nonselective beta blocker (e.g. Propranolol, Nadolol – splanchnic
vasoconstriction, decrease cardiac output) and titrate up to maximum
tolerated dose, HR 50-60
• Start as inpatient, once acute bleeding has resolved and patient shows
hemodynamic stability
Evaluation of Upper GI Bleed
• Investigations
• FBC, GXM, CLOTTING PROFILE, LFT, BUE/CR, Upper GI endoscopy
• HBV, HCV, H. PYLORI-CLO/STOOL ANTIGEN
Management of Underlying Cause of UGI
Bleeding
• PUD
• ESOPHAGEAL VARICES
• ESOPHAGITIS
• MALLORY WEIS TEAR
• GASTRIC MALINGNANCY
Lower GI Bleed
• Bleeding arising from the colorectum
• In patients with severe hematochezia, first consider possibility of
UGIB
• 10-15% of patients with presumed LGIB are found to have upper GIB
Lower GI Bleed
• Differential Diagnosis
- Diverticulosis (# 1 cause) Large volume, painless
- Angioectasias
- Hemorrhoids
- Colitis (IBD, Infectious, Ischemic) Smallerdiarrhea
volume, pain,

- Neoplasm
- Post-polypectomy
- Dieulafoy’s lesion
Q1. A 52 year old man presented with hematochezia and hypotension.
He takes 42 units of alcohol per week for the past 10years. On
examination GCS-10/15, BP-80/40 and Pulse -118bpm, weak volume. He
was jaundiced and shifting dullness was positive. All of the following are
true except

• A. Full blood count may show high MCV and low platelet counts
• B. Liver size maybe normal on clinical examination
• C. Bleeding peptic ulcer is a differential diagnosis
• D. It’s unlikely an upper GI bleeding since he’s having hematochezia
• E. Bleeding esophageal varices is the most likely diagnosis
Q2. Concerning the patient above in Q1 which is not True

• A. Propranolol can be used when patient is stable

• B. Octreotide can reduce ongoing bleeding
• C. Intravenous fluids and Blood transfusion is the most effective initial
management
• D. Sengstaken-Blakemore tube can be used in uncontrollable bleeding in
this patient
• E. Patient should be rushed for emergency endoscopy immediately to
stop bleeding
Q3 The following are features of Portal hypertension except
• A. Ascites
• B. Esophageal Varices
• C. Splenomegaly
• D. Thrombocytosis
• E. Thrombocytopenia
Q4. The following are endoscopic treatment options in a non-variceal
upper gastrointestinal bleeding except
A. Thermal Electrocoagulation
B. Hemoclips
C. Beta Blocker Injection
D. Epinephrin Injection
E. Under running of Bleeding vessel
Q5. Which of these is true concerning emergency management of
bleeding peptic ulcer
A. Early use of propranolol improves prognosis
B. Intravenous antibiotics prevents hepatic encephalopathy
C. Endoscopy must be done within 24hrs especially when patient is
unstable in order to stop the bleeding
D. Early use of intravenous PPIs may reduce bleeding
E. Endoscopic treatment options include epinephrine injection and
variceal banding
Q6 Concerning Variceal Bleeding, one of these is not true
• A. Intravenous octreotide will reduce the systemic blood pressure in
order to reduce the portal pressure
• B. Sudden collapse and death could be a presentation
• C. Proton pump inhibitor may be used prior to endoscopy
• D. Prophylactic antibiotics reduce risks of hepatic encephalopathy and
rebleeding
• E. Aggressive expansion of plasma volume from fluid resuscitation
may worsen bleeding
Q7. A 35 year old man with no history of alcohol intake was admitted with
right hypochondriac pains and jaundice of 2 months duration. His elder
brother and younger sister have been diagnosed with hepatitis B infection. On
examination he was cachectic with moderate anaemia, tender nodular liver in
the right hypochondriac region with ascites and malena stools on DRE. Full
blood count showed HB 7.9g/dl, platelet count of 98. Which of the following
is the false
• A. He certainly has portal hypertension
• B. Hepatocellular carcinoma from Hepatitis B infection is likely diagnosis
• C. His MCV may be low or high
• D. If patient does not have splenomegaly, a diagnosis of portal hypertension
cannot be made
• E. INR or PT may be elevated.