Approach to

Gastrointestinal
Bleeding

Introduction/Epidemiology

Gastrointestinal Bleeding is a common

problem in emergency medicine
Mortality is approximately 5 - 10 % with
a decrease in the past 15 years.

Vocabulary
Gastrointestinal bleeding comprises Upper &
Lower Gastrointestinal bleeding
The difference is defined by location of
source of bleeding Either proximal or distal to the ligament of
Treitz (duodenal suspensory ligament that
attaches at the junction of duodenum and
jejunum)

Prehospital Treatment

Based on patients hemodynamic status

If any signs of shock/unstable
gastrointestinal bleeding the priorty is rapid
transport
Brief initial survey to include
airway,breathing, circulation, & mechanism
of injury

Prehospital Evaluation
Look for signs of hemorrhagic shock
Altered mental status
Cool,clammy skin
Increased capillary Fill time
Tachycardia
Hypotension

Prehospital Treatment

Intubate unresponsive patients & those

unable to protect their airway
Transport in Trendelenburgs position & on
left side
No extra time at the scene should be spent
establishing intravenous access in unstable
patients
Large bore lines should be placed en
route

Prehospital Evaluation

If objective findings of bleeding at the

scene - document the amount of blood
If time permits- utilize friends, family, or
neighbors for brief history
Transport any medical records or
medications if available

Emergency Department
Treatment & Evaluation

Regardless of presentation
Require Immediate Resuscitation &
Stabilization
Monitor oxygenation with pulse oximetry
Unstable patients require 2 large bore
intravenous lines, cardiac monitoring, &
frequent vital sign checks

Emergency Department
Evaluation &Treatment

Resuscitate using Lactated Ringers or

Normal Saline - Use boluses from 250 ml to
1000 ml in order to maintain systolic blood
pressure above 90 mm Hg
If response is inadequate after 2-3 liters of
crystalloid - consider blood transfusions

Emergency Department
Management

A nasogastric tube should be placed in all

patients with significant gastrointestinal
bleeding regardless of presumed source.
Gastric Lavage
Using large-bore tube
Room temperature saline should be
used.

Emergency Department
Management

Transfusions
Packed Red Blood Cells (PRBCs)
Fresh Frozen Plasma (FFP)
Platelet Transfusions

Clinical Manifestations
GI Bleeding most commonly presents with
hematemesis, Coffee-ground emesis,
melena or hematochezia.
Hematemesis/coffee-ground emesis
suggests upper GI bleeding.
Melena suggests a source at or proximal
to right colon.
Hematochezia suggests a more distal
colorectal lesion.

GI Bleeding History

Weight loss or changes in bowel habits are

classic symptoms of malignancy.
Vomiting or retching is suggestive of a
Mallory-Weiss tear.
History of medications should be sought.
Alcohol abuse/dependence is strongly
associated with GI bleeding.

Physical Examination

Vital Signs

Skin Findings

A careful ENT examination

Abdominal Examination

Rectal Examination

Initial Diagnostic Studies

Laboratory
Most important test is to Type & Crossmatch for 4-6 units of Packed Red Blood
Cells (PRBCs)
CBC with platelets
Coagulation Studies
Electrolytes, Calcium, BUN, Creatinine, &
Glucose & Liver Function Tests.

Initial Diagnostic Studies

Obtain ECG in patients over 40 years old.

Radiography
Upright Chest X-Ray
Abdominal Films- Flat, Upright, or
Decubitus

Secondary Management

Endoscopy

Drug Therapy

Balloon Tamponade

Surgery

Upper GI Bleeding

HISTORY
Hematemesis implies an upper GI source.
Symptoms of anemia
The location of pain can be helpful.
Worsened pain and acute GI bleeding: trauma,
pancreatitis, or hematobilia.
Important questions include symptoms, use of
alcohol, NSAIDs, anticoagulants, abdominal
trauma, prior Gl bleeding, family history of GI
bleeding, recent non-intestinal GI bleeding.
Previous blood transfusions or reactions to them

PHYSICAL EXAMINATIONS

Signs of anemia
Supine hypotension
Resting tachycardia
Positive "tilt" test
Peripheral vasoconstriction
Altered mental status
Oliguria.
Look for a nasopharyngeal source
Evidence of portal hypertension
Abdominal surgical scars

Always document signs indicative of major GI hemorrhage

DIFFERENTIAL DIAGNOSIS
If hematemesis is present, rule out:
nasopharyngeal sources:
chronic inflammation, polyp, malignancy
pulmonary sources:
tuberculosis, pneumonia, bronkiectasi
coagulopathy:
D.I.C, hemophilia

LABORATORY TESTS
CBC, coagulation factors, and fibrinolysis.
LFT, kidney functions
Plain x-rays of the abdomen, if a viscus
perforation is suspected.
Endoscopic examination

NASOGASTRIC TUBE
Regardless of a positive or negative NGT
aspirate, if lower vs. upper bleed is
uncertain, leave the tube in for 12-24 hours
to detect a rebleed or duodenal reflux of
blood.
A negative NGT does not rule out an upper
GI bleed
All GI bleeders should have a nasogastric tube (NGT) placed

CAUSES
Most common:
Peptic Ulcer Disease

40-60%

Gastritis

20-35%

Varicies

8-15%

Mallory-Weiss

8-15%

CAUSES
Less Common:
Gastric Malignancy
Chronic Renal Failure
Angiodysplasia of stomach/duodenum
Esophagitis
Duodenitis
Pancreatitis, Pancreatic Neoplasm
Leukemias, DIC, Thrombocytopenia

CAUSES OF UPPER GI BLEEDING (contd)

Rare Causes:
Leiomyoma, leiomyosarcoma
Aorto-enteric fistula
Hemobilia
Duodenal diverticula
Collagen Vascular Diseases
Mucocutaneous syndromes
Osler-Weber-Rendu, Peutz-Jeghers

ALGORITHM FOR ACUTE GI BLEEDING

Patient presents with acute GI bleeding
- Evaluate ABC
- Determine past or current bleeding
- Draw blood for CBC, PT, aPTT, crossmatch

Stable
- H & PE
- NG aspirate/lavage
- Identify prognostic factors
- Endoscopy

Unstable
- Give oxygen by mask
- IV catheter
- Insert Foley catheter
- Give blood as needed
- Correct coagulopathy

Stabilized

Remain unstable:
Surgical approach

Summary
Regardless of presentation, begin
with immediate resuscitation and
stabilization.