Acute Gastrointestinal Bleeding

1. Classification by Location

2. Etiology

Upper GI Bleeding (most common causes in adults)

• Peptic ulcer disease - historically 50% of UGI bleeds; epigastric pain + hematemesis, especially in NSAID/aspirin users
• Esophagogastric varices - painless massive bleeding in a cirrhotic patient
• Mallory-Weiss tear - vomiting/retching followed by hematemesis
• Erosive gastritis/esophagitis - GERD, heavy alcohol use, odynophagia
• Dieulafoy's lesion - large submucosal artery eroding through mucosa
• Gastric antral vascular ectasia (GAVE) - "watermelon stomach," associated with scleroderma
• Aortoenteric fistula - GI bleeding in a patient with prior aortic aneurysm repair (herald bleed)

Mid-GI Bleeding

• Angioectasias - recurrent bleeding in elderly patients with chronic renal failure or aortic stenosis
• Meckel diverticulum - painless large-volume bleeding in a child or young adult
• NSAID enteropathy, Crohn's disease, small bowel tumors

Lower GI Bleeding

• Diverticulosis - painless, intermittent large-volume hematochezia (most common cause in adults)
• Internal hemorrhoids - intermittent low-volume bright red blood on tissue or dripping into toilet water
• Colon ischemia - abdominal pain + hematochezia in elderly patient with cardiovascular disease
• Angiodysplasia
• Colorectal neoplasms
• Inflammatory bowel disease

- Sleisenger and Fordtran's Gastrointestinal and Liver Disease, Table 65.2

3. Initial Assessment

History

Physical Examination

• Vital signs - tachycardia (HR >100), hypotension, orthostasis indicate significant blood loss
• Signs of hypovolemic shock - cool clammy skin, mottled skin, flat JVP, oliguria
• Stigmata of chronic liver disease - telangiectasias, palmar erythema, gynecomastia, ascites, splenomegaly, caput medusae
• Skin findings - purpura (Henoch-Schonlein purpura), pigmented lip lesions (Peutz-Jeghers), acanthosis nigricans (malignancy)
• Clinical findings most predictive of severe UGI bleeding: bright red blood in NG lavage, HR >100, hemoglobin <8 g/dL

Investigations

• CBC with platelet count
• Electrolytes, BUN/creatinine (elevated BUN:creatinine ratio suggests UGI bleeding)
• Liver function tests + coagulation profile (INR, PT)
• Type and crossmatch

- Sleisenger and Fordtran's Gastrointestinal and Liver Disease, p. 297

4. Risk Stratification

- Sleisenger and Fordtran's Gastrointestinal and Liver Disease, pp. 3203-3205

5. Resuscitation

Management Algorithm for Severe UGI Bleeding

Fig. 20.1 - Sleisenger and Fordtran's Gastrointestinal and Liver Disease

1. Airway - Prophylactic endotracheal intubation ONLY if the patient cannot protect the airway or is inadequately ventilating (routine prophylactic intubation is NOT indicated - associated with increased cardiopulmonary complications).
2. IV Access + Volume - Two large-bore IV catheters in antecubital veins; start isotonic saline.
3. Blood Transfusion:
   • Restrictive strategy: transfuse PRBCs when Hgb < 7 g/dL (supported by multiple RCTs and guidelines)
   • Higher threshold (Hgb 8-10 g/dL) for patients with ischemic cardiac disease
   • Massive hemorrhage: balanced resuscitation - 1:1:1 ratio of PRBCs : FFP : platelets
4. Hemodynamic monitoring - ICU admission for active bleeding, significant blood loss, or high-risk features: hematochezia, syncope, shock, comorbidities, or in-hospital onset. Place urinary catheter; monitor HR, BP, SpO2, urine output, mental status.
5. Nasogastric tube - Controversial; useful to detect bright red blood (increases likelihood of severe UGI source), but does not affect mortality, LOS, or transfusion need.

Management of Antithrombotic Drugs

• 29-44% of severe GI bleeds occur in patients on antithrombotic agents
• Vitamin K antagonists (warfarin) with life-threatening bleeding: reverse with 4-factor prothrombin complex concentrate (PCC) + vitamin K (FFP if PCC unavailable); do NOT delay endoscopy to await reversal
• Manage all antithrombotic agents in consultation with cardiology

6. Pharmacotherapy

Proton Pump Inhibitors (Non-variceal UGI Bleeding)

• Pre-endoscopy: Start high-dose IV PPI if peptic ulcer suspected - reduces stigmata of recent hemorrhage at endoscopy
• Post-endoscopy (high-risk stigmata): High-dose PPI bolus + continuous infusion for 72 hours

Octreotide (Variceal Bleeding)

• Drug of choice if endoscopy cannot be performed urgently
• Adult dose: 50 mcg IV bolus then 25-50 mcg/hr continuous infusion
• Pediatric dose: 1-2 mcg/kg bolus (max 50 mcg), then 1-2 mcg/kg/hr infusion (max 4 mcg/kg/hr)
• Main adverse effect: hyperglycemia

Vasopressin

• Alternative to octreotide for variceal bleeding (limited by peripheral/central vasoconstriction)
• Pediatric: 0.002-0.005 unit/kg/min, max 0.01 unit/kg/min

7. Endoscopy

Upper GI Bleeding

• Urgent EGD (within 6-12 hours): for hypotension, vomiting red blood, hematochezia, or suspected variceal bleeding
• EGD within 24 hours: stable patients with melena or coffee-ground emesis
• IV prokinetic (erythromycin or metoclopramide) 30-90 minutes before EGD improves gastric visualization and reduces need for repeat endoscopy

Forrest Classification - Peptic Ulcer Stigmata

Rebleeding rates without endoscopic therapy or PPI by Forrest classification - UCLA CURE Center

• Epinephrine injection (1:10,000 - 1:20,000)
• Coaptive thermal probe (heater probe or bipolar probe)
• Hemostatic clips
• Combination therapy is superior to monotherapy for active bleeding

Lower GI Bleeding (Colonoscopy)

• Within 12-14 hours for severe or ongoing active hematochezia (after colonic purge with 6-8 L PEG over 4-6 hours)
• Within 24 hours for mild/moderate self-limited hematochezia
• Metoclopramide 10 mg IV before/during purge to reduce nausea and facilitate gastric emptying

8. Mid-GI (Small Bowel) Bleeding

• Hemodynamically unstable: CT angiography first to localize bleeding
• Hemodynamically stable: Repeat EGD/colonoscopy (identifies source in 30-40% of cases)
• Video Capsule Endoscopy (VCE): Test of choice for stable patients; 80-90% small bowel visualization, 80% diagnostic yield (highest if performed within 2-3 days of hemorrhage); contraindicated if bowel obstruction suspected (1% capsule retention rate)
• Device-Assisted Enteroscopy (DAE): Diagnostic yield ~60%, increases to 75% after positive VCE; allows therapeutic hemostasis
• CT enterography: 40-57% yield for inflammatory/neoplastic/vascular lesions
• Tc-99m pertechnetate scintigraphy (Meckel scan): >90% sensitivity in children; <50% in adults

9. Independent Risk Factors for Persistent or Recurrent Bleeding

• Bright red blood on rectal exam or in NG aspirate
• Active arterial bleeding at endoscopy
• Large ulcer size (>2 cm)
• Posterior duodenal ulcer or lesser gastric curvature ulcer (overlying major vessels)
• Comorbid illnesses (cardiac, renal, hepatic disease)
• Coagulopathy

- Sleisenger and Fordtran's Gastrointestinal and Liver Disease, Table 20.4

10. Special Populations

Pediatric GI Bleeding

• Neonates: Swallowed maternal blood, hemorrhagic disease of newborn (Vit K deficiency), NEC
• Infants/Toddlers: Anal fissure (lower GI), Mallory-Weiss, intussusception
• Children/Adolescents: Mallory-Weiss, H. pylori gastritis, IBD, polyps, Meckel diverticulum

Cirrhosis/Portal Hypertension

• Octreotide infusion + urgent EGD (band ligation preferred over sclerotherapy for esophageal varices)
• Prophylactic antibiotics (norfloxacin or ceftriaxone) reduce bacterial infection and rebleeding

Recent Evidence Note