Gastrointestinal Bleeding


Article Author:
Alexander DiGregorio


Article Editor:
Heidi Alvey


Editors In Chief:
Jessica Snowden
Asif Noor
H Davies


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/10/2019 2:21:05 PM

Introduction

Gastrointestinal bleeding can fall into two broad categories: upper and lower sources of bleeding.  The anatomic landmark that separates upper and lower bleeds is the ligament of Treitz, also known as the suspensory ligament of the duodenum.  This peritoneal structure suspends the duodenojejunal flexure from the retroperitoneum.  Bleeding that originates above the ligament of Treitz usually presents either as hematemesis or melena whereas bleeding that originates below most commonly presents as hematochezia. Hematemesis is the regurgitation of blood or blood mixed with stomach contents. Melena is dark, black, and tarry feces that typically has a strong characteristic odor caused by the digestive enzyme activity and intestinal bacteria on hemoglobin. Hematochezia is the passing of bright red blood via the rectum.

Etiology

Upper GI Bleeding

  • Peptic ulcer disease (can be secondary to excess gastric acid, H. pylori infection, NSAID overuse, or physiologic stress)
  • Esophagitis
  • Gastritis and Duodenitis
  • Varices
  • Portal Hypertensive Gastropathy (PHG)
  • Angiodysplasia
  • Dieulafoy’s lesion (bleeding dilated vessel that erodes through the gastrointestinal epithelium but has no primary ulceration; can any location along the GI tract[1]
  • Gastric Antral Valvular Ectasia (GAVE; also known as watermelon stomach)
  • Mallory-Weiss tears
  • Cameron lesions (bleeding ulcers occurring at the site of a hiatal hernia[2]
  • Aortoenteric fistulas
  • Foreign body ingestion
  • Post-surgical bleeds (post-anastomotic bleeding, post-polypectomy bleeding, post-sphincterotomy bleeding)
  • Upper GI tumors
  • Hemobilia (bleeding from the biliary tract)
  • Hemosuccus pancreaticus (bleeding from the pancreatic duct)

 Lower GI Bleeding

  • Diverticulosis (colonic wall protrusion at the site of penetrating vessels; over time mucosa overlying the vessel can be injured and rupture leading to bleeding) [diverticulosis]
  • Angiodysplasia
  • Infectious Colitis
  • Ischemic Colitis
  • Inflammatory Bowel Disease
  • Colon cancer
  • Hemorrhoids
  • Anal fissures
  • Rectal varices
  • Dieulafoy’s lesion (more rarely found outside of the stomach, but can be found throughout GI tract)
  • Radiation-induced damage following treatment of abdominal or pelvic cancers
  • Post-surgical (post-polypectomy bleeding, post-biopsy bleeding)

Epidemiology

UGIB is more common than LGIB[3][4][5][6]

  • UGIB approx. 67/100,000 population
  • LGIB approx. 36/100,000 population
    • More common with increasing age
    • More common in men
    • Overall incidence is decreasing nationwide

History and Physical

History

  • Question patient for potential clues regarding:
  • Previous episodes of GI bleeding
  • Past medical history relevant to potential bleeding sources (e.g., varices, portal hypertension, alcohol abuse,  tobacco abuse, ulcers, H. pylori, diverticulitis, hemorrhoids, IBD)
  • Comorbid conditions that could affect management
  • Contributory or confounding medications (NSAIDs, anticoagulants, antiplatelet agents, bismuth, iron)
  • Symptoms associated with bleeding (e.g., painless vs. painful, trouble swallowing, unintentional weight loss, preceding emesis or retching, change in bowel habits)

Physical

  • Look for signs of hemodynamic instability:
    • Resting tachycardia — associated with the loss of less than 15% total blood volume
    • Orthostatic Hypotension — carries an association with the loss of approximately 15% total blood volume
    • Supine Hypotension — associated with the loss of approximately 40% total blood volume
  • Abdominal pain may raise suspicion for perforation or ischemia.
  • A rectal exam is important for the evaluation of:
    • Anal fissures
    • Hemorrhoids
    • Anorectal mass
    • Stool exam

Evaluation

Labs

  • Complete blood count
  • Hemoglobin/Hematocrit
  • INR, PT, PTT
  • Lactate
  • Liver function tests

Diagnostic Studies

  • Upper Endoscopy
    • Can be diagnostic and therapeutic
    • Allows visualization of the upper GI tract (typically including from the oral cavity up to the duodenum) and treatment with injection therapy, thermal coagulation, or hemostatic clips/bands
  • Lower Endoscopy/Colonoscopy
    • Can be diagnostic and therapeutic
    • Allows visualization of the lower GI tract (including the colon and terminal ileum) and treatment with injection therapy, thermal coagulation, or hemostatic clips/bands
  • Push Enteroscopy
    • Allows further visualization of the small bowel
  • Deep Small Bowel Enteroscopy
    • Allows further visualization of the small bowel
  • Nuclear Scintigraphy
    • Tagged RBC scan
    • Detects bleeding occurring at a rate of 0.1 to 0.5mL/min using technetium-99m (can only detect active bleeding[7]
    • Can be helpful to localize angiographic and surgical interventions
  • CT Angiography
    • Allows for identification of an actively bleeding vessel
  • Standard Angiography
    • Allows for identification of a bleeding vessel and potential treatment via embolization or intra-arterial vasopressin[8]
    • Requires the active bleeding be at a rate of 0.5 to 1.0mL/min to visualize site[9]
  • Meckel’s scan
    • Nuclear medicine scan to look for ectopic gastric mucosa

Treatment / Management

Acute management of GI bleeding typically involves an assessment of the appropriate setting for treatment followed by resuscitation and supportive therapy while investigating the underlying cause and attempting to correct it.

Risk Stratification

Specific risk calculators attempt to help identify patients who would benefit from ICU level of care; most stratify based on mortality risk. The AIMS65 score and the Rockall Score calculate the mortality rate of upper GI bleeds. There are two separate Rockall scores; One is calculated before endoscopy and identifies pre-endoscopy mortality, whereas the second score is calculated post-endoscopy and calculates overall mortality and re-bleeding risks.  The Oakland Score is a risk calculator that attempts to help calculate the probability of a safe discharge in lower GI bleeds.[10]

Setting

  • ICU
    • Patients with hemodynamic instability, continuous bleeding, or those with a significant risk of morbidity/mortality should undergo monitoring in an intensive care unit to facilitate more frequent observation of vital signs and more emergent therapeutic intervention. 
  • General Medical Ward
    • Most other patients can undergo monitoring on a general medical floor. However, they would likely benefit from continuous telemetry monitoring for earlier recognition of hemodynamic compromise
  • Outpatient
    • Most patients with GI bleeding will require hospitalization. However, some young, healthy patients with self-limited and asymptomatic bleeding may be safely discharged and evaluated on an outpatient basis. 

Treatments

  • Nothing by mouth
  • Provide supplemental oxygen if patient hypoxic (typically via nasal cannula, but patients with ongoing hematemesis or altered mental status may require intubation). Avoid NIPPV due to the risk of aspiration with ongoing vomiting.
  • Adequate IV access - at least two large-bore peripheral IVs (18 gauge or larger) or a centrally placed cordis
  • IV fluid resuscitation (with Normal Saline or Lactated Ringer’s solution)
  • Type and Cross
  • Transfusions
    • RBC transfusion
      • Typically started if hemoglobin is < 7g/dL, including in patients with coronary heart disease[11][12]
    • Platelet transfusion
      • started if platelet count < 50,000/microL
    • Prothrombin complex concentrate
      • Transfuse if INR > 2
  • Medications
    • PPIs
      • Used empirically for upper GI bleeds and can be continued or discontinued upon identification of the bleeding source
    • Prokinetic Agents
      • Given to improve visualization at the time of endoscopy
    • Vasoactive medications
      • Somatostatin and its analog octreotide can be used to treat variceal bleeding by inhibiting vasodilatory hormone release[13]
    • Antibiotics
      • Considered prophylactically in patients with cirrhosis to prevent translocation, especially from endoscopy
    • Anticoagulant/antiplatelet agents
      • Should be stopped if possible in acute bleeds
      • Consider the reversal of agents on a case-by-case basis dependent on the severity of bleeding and risks of reversal
  • Other
    • Consider NGT lavage if necessary to remove fresh blood or clots to facilitate endoscopy
    • Placement of a Blakemore or Minnesota tube should be considered in patients with hemodynamic instability/massive GI bleeds in the setting of known varices, which should be done only once the airway is secured. This procedure carries a significant complication risk (including arrhythmias, gastric or esophageal perforation) and should only be done by an experienced provider as a temporizing measure. 
    • Surgery should be consulted promptly in patients with massive bleeding or hemodynamic instability who have bleeding that is not amenable to any other treatment

Differential Diagnosis

Few diagnoses mimic GI bleeding. Occasionally, hemoptysis may be confused for hematemesis or vice versa. Ingestion of bismuth-containing products or iron supplements may cause stools to appear melanic. Certain foods/dyes may turn emesis or stool red, purple, or maroon (such as beets).

Prognosis

Limited studies exist regarding the prognosis following GI bleeding.

For upper GI bleeds, in-hospital mortality rates are approximately 10% based on observational studies.  This rate holds steady up to 1-month post-hospitalization for GI bleed.  Long-term follow-up of patients with UGIB shows that at three years after admission mortality rates from all causes approach 37%.

Mortality rates were higher in women than in men when adjusted for age, which differs from that of lower GI bleeding. Patients with multiple hospitalizations for GI bleeding carry higher mortality rates.  Long-term prognosis was worst in patients who suffered from malignancies and variceal bleeds. The prognosis was worse with advancing age.[14]

For lower GI bleeds, all-cause in-hospital mortality is low—less than 4%. Death from LGIB itself is rare, with most in-hospital mortality occurring from other comorbid conditions. Increased risk of death corresponded to increasing age (as seen in cases of UGIB as well), comorbid conditions, and intestinal ischemia. Other negative prognostic factors include secondary bleeding (onset of bleed after being hospitalized for a different condition), patients with pre-existing coagulopathies, hypovolemia, transfusion requirement, and male sex. Not surprisingly, the lowest risks of mortality are associated with more benign causes of LGIB such as hemorrhoids, anal fissures, and colon polyps.[15] Long-term follow-up studies in patients with LGIB are not common.

Complications

  • Respiratory Distress
  • Myocardial Infarction
  • Infection
  • Shock
  • Death

Consultations

  • Gastroenterology
  • Critical Care
  • General Surgery
  • Interventional Radiology

Deterrence and Patient Education

A GI bleed is any bleeding occurring from the gastrointestinal system.  This includes the esophagus, stomach, small intestine, and large intestine (also known as the colon).  Bleeding from the GI system can come from the upper GI tract (esophagus, stomach, and part of the small intestine) or the lower GI tract (second part of the small intestine and the large intestine). Some symptoms of GI bleeding are obvious, such as vomiting bright red blood or blood that looks like coffee-grounds or seeing bright red blood in the toilet with bowel movements. Some symptoms of GI bleeding are more subtle, such as dark or tar-like stools, belly pain, diarrhea, anemia (which is a low red blood cell count), weakness, lightheadedness, shortness of breath, pale skin, or a racing heart.  There are many causes of bleeding from the GI tract.  The doctor may perform a series of tests to evaluate concerns of a gastrointestinal bleed. Some of these tests check the blood for cell counts and clotting ability. Some tests include imaging to try to see from where the blood is coming.

Some tests are relatively invasive compared to others but allow for direct observation of the GI tract, such as an esophagogastroduodenoscopy (EGD) or a colonoscopy. In these procedures, the doctor gives medication to relax the patient and inserts a flexible scope with a light and camera from the mouth or the anus to observe the parts of the GI system it concerns them is bleeding.  If there is bleeding, treatment may commence with oxygen, fluids through an IV, blood transfusions, or various medications to help stop the bleeding, reduce acid production, or empty the stomach.  Patients can help avoid some causes of GI bleeding by not taking certain medications including NSAIDs (such as ibuprofen or naproxen) and receiving treatment for stomach ulcers or liver disease.

Enhancing Healthcare Team Outcomes

Care of patients with gastrointestinal bleeding requires coordinated and efficient interprofessional cooperation.  Nurses manage the frequent monitoring of vital signs and more short-term interaction with and observation of patients. They must communicate their findings with the physicians, who use their own and nursing observations to make decisions for treatment. Multiple physicians may be necessary for treatment. General internists are typically responsible for the routine care of patients with GI bleeds. Critical care physicians may be involved if the patient warrants ICU level care for severe hemorrhages. Gastroenterologists perform endoscopic examinations and treatment if able during those procedures. Radiologists will interpret various imaging modalities and conveying those results to the providers. Interventional radiologists may perform diagnostic procedures, with the ability to also perform therapeutic modalities such as angiography-guided embolization. In some severe cases, general surgeons may be involved for intervention or exploratory procedures. Pharmacists are essential for providing oversight of medications used in the setting of bleeds and ensuring the use of proper dosages. A coordinated effort by all of these healthcare professionals is necessary for early recognition and intervention in gastrointestinal bleeds to prevent further morbidity or mortalities.


  • Image 7437 Not availableImage 7437 Not available
    Olek Remesz (wiki-pl: Orem, commons: Orem) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], from Wikimedia Commons
Attributed To: Olek Remesz (wiki-pl: Orem, commons: Orem) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], from Wikimedia Commons

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Gastrointestinal Bleeding - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following is not an advantage of arteriography over radionuclide RBC scans?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Obscure gastrointestinal (GI) bleeding accounts for what percentage of all cases of GI bleeding?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is most appropriate for the initial treatment of a patient with acute gastrointestinal bleeding?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following would be the least helpful in the management of a GI bleed from an unknown source?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is not true regarding gastrointestinal bleeding in children?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the term for vomiting blood?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 57-year-old male presents to the emergency department with 30 minutes of intermittent but worsening hematemesis. His medical history includes hypertension, diabetes mellitus, chronic hepatitis C, and tobacco dependence. Intravenous access is obtained, basic labs including a type and cross, and intravenous fluid resuscitation are ordered. Which additional empiric treatment will have the greatest benefit in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 60-year-old male with a history of stable coronary artery disease, hypertension, hyperlipidemia, and constipation presents with complaints of a large amount of painless bright red bleeding per rectum for the last two days, which appears to have now subsided. He is lightheaded upon standing and appears somewhat pale. You suspect he has a large diverticular bleed. Supportive treatment is initiated. Intravenous access is obtained, and resuscitative fluids started. CBC shows a hemoglobin of 5 g/dL. What is the recommended goal hemoglobin level in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 70-year-old female with a history of hypertension and aortic stenosis is evaluated for iron deficiency anemia. A digital rectal exam reveals no hemorrhoids or anorectal masses. Stool guaiac testing is positive for occult blood. Given her history and exam findings, which of the following is the likely cause of her bleeding?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old female presents to the emergency department with two days of vomiting, abdominal pain, and bloody diarrhea. In questioning him, she notes that he recently returned from a trip to the Louisiana coast where she visited a friend and says they ate a large quantity of seafood, including some raw oysters. Which of the following is the most likely infectious agent causing her current issue?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Gastrointestinal Bleeding - References

References

Wuerth BA,Rockey DC, Changing Epidemiology of Upper Gastrointestinal Hemorrhage in the Last Decade: A Nationwide Analysis. Digestive diseases and sciences. 2018 May     [PubMed]
Ghassemi KA,Jensen DM, Lower GI bleeding: epidemiology and management. Current gastroenterology reports. 2013 Jul     [PubMed]
Longstreth GF, Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. The American journal of gastroenterology. 1995 Feb     [PubMed]
Lanas A,Perez-Aisa MA,Feu F,Ponce J,Saperas E,Santolaria S,Rodrigo L,Balanzo J,Bajador E,Almela P,Navarro JM,Carballo F,Castro M,Quintero E, A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal antiinflammatory drug use. The American journal of gastroenterology. 2005 Aug     [PubMed]
Dusold R,Burke K,Carpentier W,Dyck WP, The accuracy of technetium-99m-labeled red cell scintigraphy in localizing gastrointestinal bleeding. The American journal of gastroenterology. 1994 Mar     [PubMed]
Funaki B, Endovascular intervention for the treatment of acute arterial gastrointestinal hemorrhage. Gastroenterology clinics of North America. 2002 Sep     [PubMed]
Walker TG, Acute gastrointestinal hemorrhage. Techniques in vascular and interventional radiology. 2009 Jun     [PubMed]
Oakland K,Jairath V,Uberoi R,Guy R,Ayaru L,Mortensen N,Murphy MF,Collins GS, Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. The lancet. Gastroenterology     [PubMed]
Qaseem A,Humphrey LL,Fitterman N,Starkey M,Shekelle P, Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians. Annals of internal medicine. 2013 Dec 3     [PubMed]
Duggan JM, Gastrointestinal hemorrhage: should we transfuse less? Digestive diseases and sciences. 2009 Aug     [PubMed]
Roberts SE,Button LA,Williams JG, Prognosis following upper gastrointestinal bleeding. PloS one. 2012     [PubMed]
Strate LL,Ayanian JZ,Kotler G,Syngal S, Risk factors for mortality in lower intestinal bleeding. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2008 Sep     [PubMed]
Lee YT,Walmsley RS,Leong RW,Sung JJ, Dieulafoy's lesion. Gastrointestinal endoscopy. 2003 Aug     [PubMed]
Weston AP, Hiatal hernia with cameron ulcers and erosions. Gastrointestinal endoscopy clinics of North America. 1996 Oct     [PubMed]
Wynick D,Polak JM,Bloom SR, Somatostatin and its analogues in the therapy of gastrointestinal disease. Pharmacology     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatric-Infectious Diseases. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatric-Infectious Diseases, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatric-Infectious Diseases, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatric-Infectious Diseases. When it is time for the Pediatric-Infectious Diseases board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatric-Infectious Diseases.