1. Gastrointestinal (GI) Bleeding
Ralph Lee, MMEd(Dist), MD, FRCPC
Gastroenterologist and Assistant Professor
University of Ottawa, September 18, 2015

2. Objectives Define upper and lower gastrointestinal (GI) bleeding.
Outline the etiologies and clinical features of upper and lower GI bleeding
Apply a systematic clinical approach to GI bleeding.
Outline the investigation and management of GI bleeding
Recognize clinical indicators suggesting urgent versus non‐urgent assessment.

3. What is Gastrointestinal Bleeding? (1)
Bleeding from anywhere in the GI tract
Esophagus to rectum
Traditionally, classified into two groups, based on presumed location of bleeding:
Upper
Lower
3rd category, ‘Mid- GI’ bleeding, is present, but infrequently used

4. What is Gastrointestinal Bleeding? (2)
Upper GI (UGI) Bleeding
Traditional: Proximal to the Ligament of Treitz
New: Proximal to the Ampulla of Vater
Lower GI (LGI) Bleeding
Traditional: Distal to Ligament of Treitz
New: Distal to terminal ileum
Mid GI bleeding
New: Ampulla of Vater to terminal ileum

5. Upper GI Bleeding

6. UGI Bleeding 75 – 80% of GI bleeding
annual hospitalization rate = 160/100,000 (US)
Mortality rate = 3.5 – 10%
Sex – M:F – 2:1
 incidence with age
More likely to present with hemodynamic instability due to rich blood supply of UGI tract

7. UGI Bleeding Causes (Common)
Peptic Ulcer disease ( %)
Varices (5 - 20%)
Mallory-Weiss tears (8 - 15%)
Erosions (8 - 15%)
AV Malformations (5%)
Tumours (5%)
Dieulafoy’s lesions (1%)

8. UGI Bleeding Causes (Other)
Gastric Antral Vascular Ectasia (GAVE)
AKA ‘Watermelon’ stomach
Portal hypertensive gastropathy
Hemobilia
Hemosuccus pancreatitis
Aortoenteric fistulas
Cameron’s lesions/ulcers

9. UGI Bleeding How Do They Present? (1)
Hematemesis
Vomiting blood
Bright red blood, clots, ‘coffee ground’ emesis
Melena
Passage of black, tarry, foul-smelling stools
Digested blood
Appears with ≥ 50cc of bleeding from UGI tract
Things that mimick melena:
Iron pills - greenish
Bismuth subsalicylate (Peptol Bismol™) - non-foul smelling

10. UGI Bleeding How Do They Present? (2)
 Bowel movement frequency
Blood is cathartic and a great laxative
Rough indicator of rapidity of bleeding
Hemodynamic symptoms
Pre/Syncope
Orthostatic dizziness/lightheadedness
Chest pain, dyspnea

11. UGI Bleeding How Do They Present? (3)
(Hematochezia - red blood per rectum)
Usually sign of LGI Bleeding, but can occur with rapid UGI bleeding (i.e. ≥ 1000cc)
patient usually hemodynamically unstable
Other symptoms
Dependent on cause
Abdominal pain, heartburn, dysphagia, nausea, vomiting

12. Lower Gi Bleeding

13. LGI Bleeding 20 – 30% of gastrointestinal bleeding
Usually less hemodynamically significant, higher Hb level, less blood transfusion requirements than UGI bleeds
Increased incidence with age
Mean age at presentation: 63 – 77
Mortality rate among hospitalized acute lower GI bleeds – 2 - 4%

14. LGI Bleeding Causes Diverticulosis (25 - 65%) Cancers/polyps (17%)
Colitis/ulcers (18%)
IBD, ischemic, vasculitis, infectious, radiation-induced, NSAID-induced
Unknown (16%)
Angiodysplasia (3 - 15%)
Other (8%)
Post-polypectomy, stercoral ulcers, aorto-colonic fistulas
Anorectal ( %)
Fissures, hemorrhoids

15. LGI Bleeding How Do They Present? (1)
Red Blood per Rectum
Bright Red Blood Per Rectum (BRBPR) – left colonic?
Dark/maroon – right colonic/lower small bowel?
Stool
 frequency – blood is cathartic
 form – diarrhea
Location of blood
Surface/side of stool/dripping – perianal source?
Mixed in stool – R colonic?
(Melena)*
Usually sign of UGI bleeding, but can occur with distal small bowel, cecum or R-sided colonic bleeding source
Typically, hemodynamically stable with less rapid bleeding

16. LGI Bleeding How Do They Present? (2)
Other Symptoms
Dependent on cause
Fecal urgency, tenesmus, incontinence
Abdominal pain/cramps
Fevers/chills
Weight loss

17. GI Bleeding

18. GI Bleeding Other important historical items
Past medical history: GI
Previous PUD/H. Pylori infection?
GI Malignancy?
Previous endoscopies
Previous polypectomy
Diverticulosis
IBD
Cirrhosis?
Varices?
Cardiac
CAD, angina, MI, CHF
Previous aortic aneurysms/grafts/vascular surgery?
Previous radiation therapy?
Bleeding episodes
Medications
Anti-platelet agents (i.e. ASA, Plavix), anticoagulants (i.e. warfarin, pradaxa)
NSAIDs
Habits – EtOH
Family history:
PUD, gastric cancer
Colonic polyps, cancer
IBD

19. GI Bleeding Physical Exam (1)
Look for:
Hemodynamic instability
Intravascular depletion
Potential etiologies of bleeding
General:
Altered mentation, jaundice
Vitals
Hypotension
Tachycardia
Orthostatic changes
 in BP and/or  HR with position change from supine to standing
Suggests intravascular volume depletion of ≥ 2L
Head and Neck:
Conjunctival pallor
Scleral icterus
Dry mucous membranes, furrowed tongue, ↓ JVP
Chest:
↓skin turgor at sternal angle
Axilla: dry or moist
Abdomen:
Tenderness, masses, hepatosplenomegaly, stigmata of chronic liver disease
Digital rectal exam:
Red blood? Melena?
Hemorrhoids, fissures
Masses

20. GI Bleeding Shock SHOCK Class I Class II Class III Class IV
Blood Loss (mL)
Up to 750
>2000
Blood Loss (%)
Up to 15
15-30
30-40
>40
HR (bpm)
<100
>100
>120
>140
BP (mmHg)
Normal ↓
RR (breaths/min)
14-20
20-30
>35
Urine Output (cc/h)
>30
5-15
Insig.
CNS
Slightly anxious
Mild anxious
Anxious, confused
Confused/ lethargic

21. GI Bleeding Management (Overview)
ABC’s
Resuscitation
Focused History and Physical Exam
Upper vs. lower GI bleed
Investigations
Treatment

22. GI Bleeding Initial Management
ABC’s
Resuscitation
Intravenous (IV) access
Monitoring
Need for monitored area ? (i.e. ICU)
Cardiac, respiratory (i.e pulse oximetry)
Volume re-expansion
IV fluids
Keep patient NPO (nil per os)
Focused history and physical exam
Upper vs. lower GI Bleed

23. GI Bleeding Investigations (1)
Bloodwork
Type and crossmatch - PRBC’s, blood products
Complete Blood Cell Count
Hemoglobin
MCV – mean corpuscular volume
 MCV  Fe deficiency  chronic blood loss?
Platelets
Clotting ability
Electrolytes

24. GI Bleeding Investigations (2)
Blood Urea Nitrogen (BUN), Creatinine
Intravascular dehydration   renal perfusion 
 BUN, Cr
UGI bleed  blood digestion in stomach/duodenum   protein absorption   urea nitrogen
[BUN x 10]: Cr > 1.5:1  May suggest UGI bleed
Liver enzymes and liver function tests
INR - Coagulation status (i.e. INR)
Liver disease (i.e. cirrhosis)
 Albumin
 INR
AST > ALT
 Platelets,  MCV
(Nasogastric aspirate)

25. GI Bleeding Initial Treatment (1)
Fluid Management
IV crystalloids (i.e. normal saline); colloids (i.e. volume expanders)
Transfusion - Packed red blood cells
Reverse anti-coagulation
 INR - Vitamin K, fresh frozen plasma, prothrombin complex concentrate (i.e. Octaplex)
 Platelets – Platelets transfusion

26. GI Bleeding Initial Treatment (2)
Pharmacotherapy
UGI Bleeds:
IV Proton Pump Inhibitor
Mechanism: ↑ pH > 6  Promotes clot stability
↓ acid/pepsin on lesion
↑ platelet aggregation + fibrin formation
Empirically started to treat possible PUD until EGD performed
IV PPI before endoscopy:
Lau et al. (2007): ↓ need for endoscopic therapy + accelerated healing of ulcers
Cochrane Meta-analysis (Sreedharan et al., 2010):
DOESN’T:  mortality, rebleeding or progression to surgery
DOES:  high risk stigmata, need for endoscopic therapy
IV PPI after endoscopic therapy:  rebleeding,  mortality
Dose: Pantoprazole 80mg IV bolus, then 8mg/h x 72 hours

27. GI Bleeding Initial Treatment (3)
IV Somatostatin (i.e. octreotide)
For possible variceal bleeds (i.e. patients with cirrhosis) – started empirically
Mechanism: splanchnic vasoconstriction   portal hypertension   bleeding
Prokinetics (20 – 120 minutes before)
i.e. metoclopramide (Maxeran) or IV erythromycin
To clear UGI tract of blood for better visualization
Meta-analysis (Barkun et al., 2010):  need for repeat endoscopy
LGI Bleeds: No specific medications

28. Urgent vs. Non-urgent Management
Hematemesis
Serious co-morbid illness
Malignancy, cirrhosis
Hemodynamic instability
Shock
SBP < 100mmHg
HR > 100bpm
(Orthostatic hypotension)
Hb < 80
Transfusion requirement > 2u PRBC’s
Severe, ongoing bleeding
Young, healthy, minimal bleeding

29. GI Bleeding Endoscopy UGI Bleed – EGD LGI Bleed – Colonoscopy
Timing: Within 24 hours of presentation
To:
Diagnose cause of bleeding (high sensitivity/specificity)
Stratify risk of rebleeding/adverse events
Potentially treat underlying pathology
LGI Bleed – Colonoscopy
Timing: Controversial
Severe bleeds: Within 8 – 24 hours
Generally, LGI bleeds less severe than UGI bleeds
Often, more difficult to identify source; therefore, mostly diagnostic rather than therapeutic
Unclear: EGD  Colonoscopy

30. Upper vs. Lower Endoscopy Presumed Upper GI Bleed
Hematemesis
EGD

31. Upper vs. Lower Endoscopy Presumed Lower GI Bleed

32. Upper vs. Lower Endoscopy Massive Rectal Bleeding

33. Upper vs. Lower Endoscopy Occult Bleeding
Stool testing positive for occult blood
Unexplained Fe deficiency anemia

34. GI Bleeding Endoscopic Hemostasis (1)
Injection
i.e. Vasoconstrictors (i.e. epinephrine), saline, sclerosants, tissue adhesives
Creates submucosal cushion of fluid which tamponades site +/- vasoconstriction
Thermal therapy
i.e. Mono/bipolar electrocoagulation, Argon Plasma Coagulation (APC), Laser Photocoagulation
Cauterizes vessel closed

35. GI Bleeding Endoscopic Hemostasis (2)
Mechanical therapy
i.e. Hemoclips, rubber bands
Closes and tamponades vessel
Animation
Hemospray
New therapy
Nano particle spray

36. UGI Bleeding Peptic Ulcer Disease (1)
Most commonly due to NSAIDS, H. Pylori
75 – 80% stop spontaneously
Ulcer appearance indicates risk of rebleeding and determines whether therapy required
Forrest Classification

37. UGI Bleeding Peptic Ulcer Disease (2)
Endoscopic intervention:
 Risk of rebleeding
 Need for surgery
 Mortality

38. UGI Bleeding Varices Often unstable UGI bleeds Esophageal – Options:
Ligated with rubber bands (band ligation)
Injection with sclerosants
Gastric – Options:
Injected with ‘glue’ (cyanoacrylate)
Band Ligation
If endoscopy unsuccessful:
Transjugular intrahepatic portosystemic shunt (TIPS)
Liver transplant

39. LGI Bleeding Diverticular Bleeding
Complicates 3 – 15% with colonic diverticulae
Pathophysiology:
Trauma of vasa recta at neck or dome of diverticulum
Presentation:
Painless hematochezia
Treatment:
% resolve spontaneously
Recurrence within 4 years
25 – 40%
Endoscopic hemostasis
If site can be identified
< 30d rebleeding: Uncommon
Angiography (85% effective)
< 30d rebleeding: 22%
Surgical resection

40. LGI Bleeding Angiodysplasia
Increases with age
Pathophysiology
Degenerative changes
Chronic, intermittent obstruction of submucosal vessels
Presentation
Usually asymptomatic
Overt or occult bleeding
Usually in right colon
Treatment
Iron replacement
Cauterization if bleeding or Fe deficiency anemia
(Estrogen/progesterone)

41. GI Bleeding Other Options (1)
If endoscopy fails to identify source or fails to stop the bleeding
Mesenteric angiography
Performed by interventional radiology
Catheter introduced through femoral artery, passed to celiac trunk, SMA, IMA + branches to:
Diagnose bleeding site
Requires blood loss of ≥ 0.5-1mL/min
Low sensitivity (47%) but high specificity (100%)
Perform therapy
Feeding arteries can be embolized with microscopic gel foam, microcoils or EtOH particles
Success rate: 52 – 94%
Complications (17%): Nephrotoxicity, bowel infarction, hematomas

42. GI Bleeding Other Options (2)
RBC scan
Patient infused with technetium tagged RBC’s to locate site of bleeding
Disadvantages:
Not therapeutic
Only localizes bleeding to generalized area of abdomen
Requires blood loss ≥ 0.1mL/min
Higher sensitivity; lower specificity
Surgery
Intraoperative enteroscopy
Oversew, resection

43. Summary (1) Upper GI Bleed Lower GI Bleed Hematemesis Melena
Hemodynamic instability
Elevated BUN x 10: Cr
Dark/bright red blood per rectum
(hematochezia)
Longer course
Tend to be more hemodynamically stable

44. Summary (2) PUD is most common cause of UGIB bleeding
Diverticular disease is the most common cause of significant LGIB
Approach includes
ABC’s
Resuscitation
History and Physical Exam
Initial Investigations
Initial Treatment
Endoscopy
Radiology
Surgery
IV PPI’s are started empirically if UGIB is suspected
Endoscopy is the primary diagnostic and therapeutic tool for GI bleeds

45. Questions?