Selmar Maribojo Jr, MD

First Year Medical Resident

 Most common gastrointestinal condition
leading to hospitalization in the United States
 Presents either Overt GI bleeding or Occult
GI bleeding
 Site of bleeding:
 UGIB (esophagus, stomach, duodenum)
 LGIB (colonic)
 Small intestinal or obscure GIB (if the source is
unclear).
 Hematemesis
 Vomitus of red blood or “coffee-grounds” material
 Melena
 Black, tarry stool
 Blood has been present in the GI tract for ≥14 h,
and as long as 3–5 days.
 Hematochezia
 Passage of red or maroon blood from the rectum
 Present with symptoms of blood loss or
anemia
 Lightheadedness
 Syncope
 Angina
 Dyspnea
 Iron-deficiency anemia
 Positive fecal occult blood test on routine testing
 Heart rate and Blood pressure - best way to
initially assess a patient with GIB
 Acute GIB
 Hemoglobin does not fall immediately at initial
presentation
 Chronic GIB
 May have very low hemoglobin values despite
normal blood pressure and heart rate.
 Hemoglobin does not fall immediately with
acute GIB
 Hemoglobin does not fall immediately with
acute GIB
 may be normal or only minimally decreased
 Hemoglobin does not fall immediately with
acute GIB
 may be normal or only minimally decreased

Extravascular fluid
GI bleeding enters the vascular
episodes space
 Hemoglobin does not fall immediately with
acute GIB
 may be normal or only minimally decreased

Extravascular fluid
GI bleeding enters the vascular
episodes space

72 hours
 Hemoglobin does not fall immediately with
acute GIB
 may be normal or only minimally decreased

Extravascular fluid
GI bleeding enters the vascular ↓Hgb falls
episodes space

72 hours
 Hemoglobin does not fall immediately with
acute GIB
 may be normal or only minimally decreased

Extravascular fluid
GI bleeding enters the vascular ↓Hgb falls
episodes space

Hemoglobin below
7g/d
 Upper GIB source
 Hematemesis
 Hematochezia
▪ May bleed so briskly that blood transits the bowel
before melena develops.
▪ Associated with hemodynamic instability and dropping
hemoglobin
 Hyperactive bowel sounds
 Elevated blood urea nitrogen
 Small bowel source
 Melena or Hematochezia
 Lower GIB source
 Hematochezia
Upper GI Source of Small-Intestinal Colonic source of
Bleeding Sources of Bleeding Bleeding
Peptic Ulcer Disease Vascular ectasias Hemorrhoid
Mallory Weis Tears Neoplasm Anal fissure
Esophageal Varices NSAID-induced erosions Diverticulosis
and ulcers
Erosive Disease Meckel’s diverticulum Vascular ectasias
Neoplasm Crohn’s disease Neplasm
Vascular ectasias Polyposis syndromes Colitis
Dieulafoy lesion Dieulafoy’s lesions Postpolypectomy
Aortoenteric fistulas Aortoenteric fistulas Radiation proctopathy
Hemobilia Small-bowel varices Aortocolic fistulas
Hemosuccus pancreaticus Diverticula Rectal varices
Intusseption Inflammatory bowel
disease
Duplication cyst Juvenile polyps.
 Peptic ulcer
 Mallory weiss Tear
 Esophageal varices
 Erosive Disease
 Less common:
 Neoplasms
 Vascular ectasias
 Dieulafoy’s lesion
 Prolapse gastropathy
 Aortoenteric fistulas
 Hemobilia
 Hemosuccus pancreaticus
 Most common cause of UGIB
 ~50% of UGIB hospitalizations.
 Features of an ulcer at endoscopy provide
important prognostic information
 High risk ulcer:
▪ Active bleeding, nonbleeding visible vessel, adherent
clot
 Low risk ulcer:
▪ Flat pigmented spot or clean base
 Indications:
 Active bleeding, nonbleeding visible vessel or
adherent clot
 Perform early
 Reductions in bleeding, hospital stay,
mortality, and costs
 Heater Probe, Bipolar electrocoagulation, Injection
therapy (e.g., absolute alcohol, 1:10,000
epinephrine), and/or clips
 Flat pigmented spot/Clean-based ulcers
 Have rates of serious recurrent bleeding
approaching zero.
 Do not require endoscopic therapy and receive
standard doses of oral PPI.
 If stable with no other reason for hospitalization,
may be discharged home after endoscopy
 Treatment: High-dose, constant-infusion IV
proton pump inhibitor (80-mg bolus and 8-
mg/h infusion)
 Sustain intragastric pH >6
 Enhance clot stability
 Decreases further bleeding and mortality in
patients with high-risk ulcers
 High-dose intermittent PPIs are non-inferior
to constant-infusion PPI therapy
 Active Flat
Endoscopic
bleeding Adherent clot pigmented Clean base
features visible vessel spot

Endoscopic
yes May consider no no
Therapy

Medical Intensive PPI Intensive PPI Once daily PPI Once daily PPI
Therapy Therapy Therapy Therapy therapy

Clear liquids x Clear liquids x Clear liquids x

Diet Regular diet
2 days 2 days 1 day

Hospital stay 3 days 3 days 1-2 days Discharge

•Vomiting Endoscopic Active No active
features bleeding bleeding
•Retching
•Coughing
Endoscopic
preceding Yes No
Therapy
hematemesis
•Alcoholic patient Medical Antiemetic if Antiemetic if
Therapy nausea nausea

Clear liquids x
Diet Regular
1 day

Hospital stay 1-2 days discharge

 Poorer outcomes
 Urgent endoscopy within 12 h is recommended in
cirrhotics with UGIB
 Endoscopic ligation should be performed
 Medical therapy:
 IV vasoactive medication (octreotide, somatostatin,
vapreotide, terlipressin) is given for 2–5 days.
 Nonselective beta blockers plus endoscopic
ligation
 Showed reduction of recurrent esophageal variceal
bleeding.
 Transjugular intrahepatic portosystemic
shunt (TIPS)
 Recommended in patients who have persistent or
recurrent bleeding despite endoscopic and
medical therapy.
 Considered in the first 1–2 days of hospitalization
for acute variceal bleeding in patients with
advanced liver disease
Endoscopic
Ligation
Therapy
Followed by
Medical Vasoactive Octreotide 50 50mcg
Therapy drug mcg IV bolus infusion for 2-
5 days
Clear liquids
Diet
for 2 days

Hospital stay 3-5 days

 Visualized breaks which Endoscopic
No
Therapy
are confined to the
mucosa Medical Once daily
Therapy therapy
 Causes:
 NSAID use Diet Regular
 Alcohol intake
 H. pylori infection Hospital stay discharge
 Stress-related mucosal
injury.
 Stress-related mucosal injury
 Occurs only in extremely sick patients,
▪ Serious trauma
▪ Major surgery
▪ Burns covering more than one-third of the body surface
▪ Major intracranial disease
▪ Severe medical illness
 Mortality rate in these patients is high because of
their serious underlying illnesses.
 Erythromycin 250mg IV
 Promotility agent
 Given ~30 min before endoscopy,
 Improve visualization : provides a small but
significant increase in diagnostic yield and
decrease in red cell transfusions.
 Quinolone or Ceftriaxone:
 Should be given with Cirrhotic patients presenting
with UGIB
 IV vasoactive medication
 Improve control of bleeding in the first 12 h after
presentation
 Upper endoscopy
 Performed within 24 h in most patients with UGIB.
 Patients at higher risk (e.g., hemodynamic
instability, cirrhosis) may benefit from more
urgent endoscopy within 12 h.
 Early endoscopy is also beneficial in low-risk
patients for management decisions (e.g.,
discharge).
 Obscure GIB
 Patients without a source of GIB identified on
upper endoscopy and colonoscopy
 75% of GIB previously labeled obscure
 Estimated to originate in the small intestine
beyond the extent of a standard upper endoscopic
exam.
 Small-intestinal GIB may account for up to
~5–10% of GIB cases.
 Most common causes in adults >40 years
 Vascular ectasias, neoplasm (e.g., GI stromal
tumor, carcinoid, adenocarcinoma, lymphoma,
metastases), and NSAID-induced erosions and
ulcers.
 Causes in patients <40 years
 Crohn’s disease, polyposis syndromes, or
neoplasm
 Meckel’s diverticulum
 Most common cause in children
 Small-intestinal vascular ectasias are treated
with endoscopic therapy
 Rebleeding is common:
 45% over a mean follow-up of 26 months
 Treatment:
 Octreotide
 Surgical resection
 Hemorrhoids - most common cause of LGIB
 Other causes:
 Diverticulosis
 Vascular ectasias
 Neoplasms
 Colitis
 Postpolypectomy bleeding
 Radiation proctopathy.
 Rarer causes
 Solitary rectal ulcer syndrome
 Trauma
 Varices (most commonly rectal)
 Lymphoid nodular hyperplasia
 Vasculitis
 Aortocolic fistulas
 In children and adolescents,
 Inflammatory bowel disease
 Juvenile polyps.
 Diverticular bleeding
 Abrupt in onset
 Usually Painless
 Sometimes massive
 Often from the right colon
 Chronic or occult bleeding is not characteristic.
 Stop bleeding spontaneously in ~80–90%
 Rebleed in ~15–40% of patients..
 Endoscopic therapy
 Decrease recurrent bleeding in the uncommon
case when colonoscopy identifies the specific
bleeding diverticulum
 Transcatheter arterial embolization by
superselective technique
 Stops bleeding in a majority of patients.
 Segmental surgical resection
 Recommended for persistent or refractory
diverticular bleeding
 Patients with hematochezia and
hemodynamic instability should have
“upper endoscopy” to rule out an upper GI
source before evaluation of the lower GI tract.
 Colonoscopy
 After an oral lavage solution is the procedure of
choice in most patients admitted with LGIB
 Bleeding is too massive  Angiography
 Computed tomography (CT) angiography
 Suggested prior to angiography to document
evidence and location of active bleeding.
 Sigmoidoscopy
 Used primarily in patients <40 years old with
minor bleeding.
 Imaging studies: 99m Tc-Labeled red cell scan
 In patients with no source identified on
colonoscopy
 allows repeated imaging for up to 24 h and may
identify the general location of bleeding.
 Angiography
 The initial test, with CT angiography or 99mTc-
labeled red cell scan prior to angiography if the
patient’s clinical status permits.
 Repeat upper and lower endoscopy may be
considered as the initial evaluation because
second-look procedures identify a source in
up to ~25% of upper endoscopies and
colonoscopies
 Video capsule endoscopy.
 Showed the yield of “clinically significant
findings”.
 Disadvantage:
▪ Does not allow full visualization of the small intestine
▪ Tissue sampling
▪ Application of therapy.
 CT enterography
 Used initially with possible small bowel narrowing
(e.g., stricture, prior surgery or radiation, Crohn’s
disease)
 Given its higher sensitivity for small-intestinal
masses.
 Deep” enteroscopy (double-balloon, single-
balloon, or spiral enteroscopy)
 Commonly the next test undertaken for clinically
important GIB documented or suspected to be
from the small intestine
 Allows to examine, obtain specimens from, and
provide therapy to much or all of the small
intestine.
 No Hemodynamicaly
instability

Age < 40 years Site identified,

Bleeding stop

Minimal Copious
Bleeding bleeding, Site identified,
Angiography/
Fx of Colon CA, Bleeding
Surgery
IDA persist

Flexible
Sigmoidoscopy Work up for
small
Site not intestinal/
Colonoscopy
identified Obscure
bleeding site
 No Hemodynamicaly
instability

Age ≥ 40 years Site identified,

Bleeding stop

Site identified,
Colonoscopy Angiography/
Bleeding
Surgery
persist

Work up for
small
Site not intestinal/
identified Obscure
bleeding site
 Hemodynamicaly instability

Upper Site identified,

Endoscopy Bleeding stop

No Upper GI Site identified,

Angiography/
source Bleeding
Surgery
persist

Unable to prep Work up for

small
Site not intestinal/
Angiography Colonoscopy
identified Obscure
bleeding site
 Hemodynamicaly instability

Upper
Endoscopy
Surgery (with
intraoperative
endoscopy if
No Upper GI site has not
source been
identified)

Unable to prep
Bleeding,
Angiography Instability
persist
 Recommended only for colorectal cancer
screening
 Age 50 in average-risk adults.
 Positive test  colonoscopy
 Negative  no further workup, unless iron-
deficiency anemia or GI symptoms are present.
Upper GI Source of Small-Intestinal Colonic source of
Bleeding Sources of Bleeding Bleeding
Peptic Ulcer Disease Vascular ectasias Hemorrhoid
Mallory Weis Tears Neoplasm Anal fissure
Esophageal Varices NSAID-induced erosions Diverticulosis
and ulcers
Erosive Disease Meckel’s diverticulum Vascular ectasias
Neoplasm Crohn’s disease Neplasm
Vascular ectasias Polyposis syndromes Colitis
Dieulafoy lesion Dieulafoy’s lesions Postpolypectomy
Aortoenteric fistulas Aortoenteric fistulas Radiation proctopathy
Hemobilia Small-bowel varices Aortocolic fistulas
Hemosuccus pancreaticus Diverticula Rectal varices
Intusseption Inflammatory bowel
disease
Duplication cyst Juvenile polyps.