1. Gastrointestinal bleeding
Ehud Melzer M.D.
Kaplan Med Ctr

2. Forms of bleeding
Upper
Lower
Occult
Obscure

3. Presentation
Hematemesis – vomiting of blood (or coffee ground material) (indicates bleeding proximal to the Treitz)
Melena – passage of black tarry stools > 50ml (indicates degradation of blood in the bowel)
Hematochezia (rectal bleeding) – passage of red blood
Occult bleeding – bleeding that is not apparent to the patient and results from small amounts of blood
Obscure bleeding – occult or obvious but source not identified

4. Initial patient assessment (acute bleeding)
Assess severity of bleeding:
Vital signs
Resuscitation:
2 large-bore IV lines
Volume replacement
Oxygen
Careful hemodynamic & electrolyte monitoring (preferably in ICU)
Transfuse blood when indicated

5. Initial patient assessment
History: (should be taken during resuscitation and not instead of)
Age:
elderly pts tend to bleed from lesions less common than young pts (i.e. diverticula, ischemic colitis, cancer)
Young pts may bleed from Meckel’s diverticula
previous bleeding:
ulcer
hereditary telangiectasia (Osler-Weber-Rendu)
diverticula
Previous surgery:
Aortic graft
Tumor

6. Initial patient assessment
Known liver disease
NSAID’s
Associated abdominal pain (ulcer, malignancy, mesenteric or colonic ischemia)
Retching (Mallory-Weiss)
Change in bowel habits, anorexia, weight loss (suspect malignancy)

7. Initial patient assessment
Physical examination:
Skin:
Spider angiomata
Telangiectasia
Hyperpigmentation (Peutz-Jegher)
Abdomen:
Hepato-splenomegaly
Ascites
Caput medusae
Tenderness
Mass
Lymphadenopathy

8. Lab
Hemoglobin:
in early stage of acute bleeding does not reflect actual amount of blood loss
Chronic overt or occult bleeding: hypochromic microcytic anemia reflecting iron deficiency
Urea: may be elevated in upper GI bleeding out of proportion to elevation of creatinine (breakdown of blood proteins by bacteria)
Fe, transferrin. ferritin

9. Clinical localization of bleeding
Hematemesis – always UGI source
Melana – indicates that blood has been in GIT for extended periods –
Mostly UGI
Small bowel
Rt colon (if bleeding relatively slow)
Hematochezia –
Mostly colon
Massive UGI bleeding (not enough time for degradation)

10. Acute UGI bleeding
Following resuscitation the diagnostic tool of choice is gastroscopy
Endoscopic therapy
Timing
Visibility

11. Acute UGI bleeding - Esophagitis
< 10% of cases
Tx – aimed at the cause – mainly reflux disease

12. Acute UGI bleeding - Mallory-Weiss Tear
Mucosal laceration at the GEJ
10% of cases
Typically follows retching but mostly on 1st vomit (75%)
90% stop bleeding spontanuously
Endoscopic Tx sometimes required

13. Acute UGI bleeding – portal hypertension
Source of bleeding –
Esophageal varices
Gastric varices
Portal hypertensive gastropathy
Urgent gastroscopy –
Sclerotherpay
Band ligation
Somatostatin
Antibiotic prophylaxis (quinolones?)
Balloon tamponade (Sengstaken-Blackmore tube)

14. Acute UGI bleeding – duodenal & gastric ulcer
Most common etiology of UGI bleeding
Duodenum>stomach
Predisposing factors for bleeding –
NSAID’s
Underlying medical conditions: IHD; cerebrovascular disease
Ethanol, anticoagulant Tx
Hospitalization

15. Acute UGI bleeding – duodenal & gastric ulcer
Gastric acid
H. Pylori: Role in bleeding not certain but definitely, eradication prevents rebleeding
Aspirin & NSAID’s:
Gastric>duodenal
Dose dependant risk
Preparation dependant
Older age – higher risk for bleeding

16. Acute UGI bleeding – duodenal & gastric ulcer
Endoscopic signs predictive of rebleeding:
Active bleeding
Visible vessel
Adherent clot
Management:
Medical Tx – IV PPI’s
Endoscopic injection
Endoscopic coagulation
Angiography + embolization
Surgery

17. Acute UGI bleeding – duodenal & gastric ulcer
Prevention of rebleeding:
Eradication of H. Pylori
If NSAID induced – avoid if possible or add high dose H2B or PPI for as long as treated with NSAID
Gastric ulcer should be always biopsied and followed until complete healing

18. Acute UGI bleeding – gastric erosions
NSAID’s
Stress:
Serious trauma
Extensive burns
Major surgery
Major illness (ICU)
Major neurologic disease (CVA, tumor, trauma)
Alcohol abuse

19. Acute UGI bleeding – malignancy
Malignant:
Esophageal cancer
Gastric cancer or lymphoma
Small intestinal lymphoma or cancer
Benign:
Leiomyoma
Gastro-Intestinal-Stromal-Tumor (GIST)

20. Acute UGI bleeding – vascular lesions
Dieulafoy
Angiodysplasia
Osler-Weber-Rendu syndrome

21. The surgeon’s point of view

22. Acute lower GI bleeding
Initial management – similar to acute upper GI bleeding
Presentation: wide range of presentation:
Mostly self-limiting bleeding that does not require hospitalization
Rarely massive with hemorrhagic shock

23. Acute lower GI bleeding
Evaluation of source:
History:
Age (tumors & diverticular disease more common in elderly pts; IBD more common in young)
HIV (CMV colitis)
NSAID’s
Family or personal Hx of polyps or CRC
Change in bowel habits
Pain (in IBD, ischemic colitis…); Anal pain
Previous abdominal irradiation
Previous surgery (particularly vascular)
ASCVD (ischemic colitis)

24. Acute lower GI bleeding
Diagnostic procedures:
Colonoscopy (urgent??)
Tagged RBC- scintigraphy – low predicrive value
Angiography + embolization (diagnostic only if bleeding is severe)
Surgery (rare)

25. Acute lower GI bleeding diverticular disease of colon
Common cause (25%)
Acute, painless, bright red, maroon or melena (depending on site)
May compromise hemodynamics (elderly)
Diagnosis: per exclusion
Significant recurrence
Tx: most subside spontaneously, some need angiographic embolization or surgery

27. Acute lower GI bleeding angiodysplasia
Presentation:
Acute (recurrent)
Chronic
Occult
Older pts (mainly>70)
High association with CRF
Most – Rt colon

28. Acute lower GI bleeding angiodysplasia
Diagnosis:
Colonoscopy
Angiography
Treatment:
Electrocoagulation
Argon-Plasma-Coag (APC)
Injection
Clips
Surgery

29. Acute lower GI bleeding neoplasia
Presentation:
Chronic
Occult
Acute (rare)
Diagnosis:
colonoscopy
Tx: according to lesion

30. Acute lower GI bleeding hemorrhoids
Most common cause
Presentation:
recurrent low-volume bright red blood on the paper or on stool
Straining aggravates bleeding
Rarely associated with anemia (acute or chronic)
Never relate bleeding to hemorrhoids before exclusion of other lesions
Diagnosis: always colonoscope after age 50. Otherwise at least sigmidoscope

31. Acute lower GI bleeding other causes
Meckel’s diverticulum (young children)
Infectious colitis:
Shigella; Salmonella; campylobacter
Pseudo-membranous colitis (rarely bloody; Klebsiella sp.)
Radiation proctitis
Ischemic colitis
IBD – colitis (UC;CD)

33. Occult bleeding Fecal Occult Blood Test (FOBT):
+ive if bleeding > 2ml/d
Good for CRC screening only (reduces mortality)
Of no value when iron deficieny already present

34. Occult bleeding History: Physical examination: Age Anticoagulation
Family Hx (CRC; polyposis; Osler-Weber-Rendu)
Menses
Physical examination:
Skin: Pallor; Telangiectasia; Café aux lait (neurofibromatosis); hyperpigmentation
Lymphadenopathy
Abdominal mass

35. Occult bleeding Diagnosis: Imaging of the colon (for Fe def & FOBT):
Colonoscopy
CTC
?? Gastroscopy (controversial for FOBT)
Small bowel follow-through (controversial for FOBT)
Video-capsule (controversial for FOBT)

36. Iron deficiency Low hemoglobin Microcytosis + hypochromia
Low serum iron + high transferin (saturation < 15%)
Low ferritin (acute phase reactant)

37. Iron deficiency D.D. Chronic/occult blood loss: Esophagus: Stomach:
Esophagitis
Tumor
Stomach:
Gastric ulcer
Small intestine:
Chronic inflammation (Crohn’s disease)
Angiodysplasia
Colon:
Inflammation (CD, UC)

38. Iron deficiency D.D. Iron malabsorption: Celiac disease
Chronic parasite infestation (Ankylostoma)

39. Iron deficiency evaluation
History:
Age
Menses
Pain
Bowel habits
Wt loss
Physical examination:
Pallor LN
Masses

40. Iron deficiency evaluation
Procedures:
Colonoscopy/Barium enema
Gastroscopy+small bowel biopsy
Small bowel follow-through
Enteroscopy
Video-capsule
Meckel scan
Angiography

41. The surgeon’s point of view