1. From Mouth to Rectum and Everywhere in Between
GI Bleeding:
From Mouth to Rectum and Everywhere in Between

2. Outline Epidemiology and Risk Factors Signs and Symptoms
Physical Exam Findings
Etiologies
Diagnosis
Management
Will focus mostly on inpatients

3. Key Point: Mortality LGIB < UGIB < Variceal bleeds
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

4. Risk Factors Most Important Part of History!
Key Point:
Risk Factors Most Important Part of History!
NSAID Use
Cirrhosis
Anticoagulation/Coagulopathy
Age
Risk factors for colon cancer
Previous history of GI bleeding

5. Signs and Symptoms Lightheadedness/Syncope Diarrhea Anemia Hematemasis
Upper GI Bleed
Lower GI Bleed
Lightheadedness/Syncope
Diarrhea
Anemia
Hematemasis
Melena
Stigmata of cirrhosis
Heartburn
Lightheadedness/Syncope
Diarrhea
Anemia
Hematochezia

6. Physical Exam Findings
Vital signs (more later)
Dry mucus membranes
Stigmata of cirrhosis
Fetid breath
DRE – gotta do it
Weak pulses
Cool skin
Encephalopathy

7. Common Etiologies PUD – 55 % Varices – 14 % AVMs – 6%
Upper GI Bleed
Lower GI Bleed
PUD – 55 %
Varices – 14 %
AVMs – 6%
Mallory Weiss Tears – 5%
Tumors/Erosions – 4%
Dieulafoy’s lesions – 1%
Others 15%
Diverticular disease – 30%
Colitis – 18%
Ischemic
Inflammatory
Infectious
Neoplasms – 10%
AVMs – 8%
Hemorrhoids – 5%
Others – 20%
Khilani et all, Emerg Med 37(10):27-32, 2005

8. Diagnosis Upper or Lower? Still bleeding? What’s the etiology? History
Digital Rectal Exam
Hemoglobin
Still bleeding?
Consider NG Lavage
What’s the etiology?
Diagnostic Testing
Freebees
These can usually make the diagnosis

9. For more information, do a GI fellowship!
Diagnostic Testing
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!

10. Management – General Principles
Risk stratify
Assess blood loss
Blatchenford score
Rockall score (after EGD)
IV access
Volume replacement
Acid suppression therapy
Plan for diagnostic procedure
Beyond the scope of this discussion!

11. Management: Assess Blood Loss
Category
% loss HR BP
Pulse Pressure
UOP
Stage 1
<15 %
< 100
Normal
> 30
Stage 2
15-30%
> 100
Decreased
20-30
Stage 3
30-40%
> 120
5-15
Stage 4
> 40%
> 140
Negligible
From Advanced Trauma Life Support Guidelines
HR not useful if patients are on AV node blockers
Tachycardic means they have lost about 1 liter of blood!
If they are hypotensive, you are in trouble!
Key Points

12. Management: Access and Volume
IV Access
Two large bore peripheral IVs is best
Volume replacement
Normal saline
Blood products
Consider FFT/Cryo/FFP

13. MGMT: Acid Suppression
Applies to UGIB from ulcers
Key Point: PPIs can improve mortality
Gralnek I.M et al. NEJM 2008

14. MGMT: Acid Suppression (con’t)
Other questions:
Continuous versus bolus?
IV versus oral?
Duration of treatment?

15. Management – Suspected Varices
Initial stabilization
Splanchnic Vasoconstricters: Octreotide/Vasopressin
TIPS
Minnesota tube/Blakemoore tube
Antibiotic prophylaxis
A whole other talk

16. 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

17. Questions?