Lower GI Bleeding

-Acute lower gastrointestinal (GI) bleeding refers to blood loss of recent onset originating from the colon.

-Upper GI bleeding presents with melena or hematemesis, whereas lower GI bleeding produces passage of bright red or maroon stools

Common causes: Diverticulosis, malignancy, polyps, colitis, hemorrhoids, anal fissures

Less common: angiodysplasia, ulcers,malignancy

Physical examination: Look for signs of hypovolemia (hypotension, tachycardia)

Laboratory tests: complete blood count, serum chemistries, liver tests, and coagulation studies

Diagnosis: Anoscopy, sigmoidoscopy, colonoscopy, radionuclide imagine, CT angiography,

Treatment: Fluid resuscitation, blood transfusions, therapeutic colonoscopy, intra-arterial embolization, surgery.

Q: What is the most common cause of major lower tract bleeding? Diverticulosis

Q: What is the initial examination of choice for the diagnosis and treatment of acute lower GI bleeding? Colonoscopy

Acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding

-Upper GI bleeding is defined as bleeding above the ligament of Treitz.

-Patients with acute upper gastrointestinal (GI) bleeding commonly present with hematemesis (vomiting of blood or coffee-ground-like material) and/or melena (black, tarry stools)

-Upper GI bleeds are 4–8 times more common than lower GI bleeds.Peptic ulcer disease accounts for at least 50% of upper GI bleeds.

-The most common presentation of upper gastrointestinal bleeding –

Hematemesis: either red blood or coffee-ground emesis (proximal to ligament of Treitz)

Melena: black, tarry stool (proximal to ligament of Treitz)

Hematochezia: red or maroon blood in the stool, usually due to lower GI bleeding (distal to ligament of Treitz)

Causes of GI bleeding:

Common Causes

-Peptic ulcers account for 40% of major upper gastrointestinal bleeding.

-Portal hypertension from esophageal varices, gastric, duodenal varices.

-Mallory-Weiss tears: lacerations of the gastroesophageal junction.

Less common: Angiodysplasia, gastritis, malignancy, esophagitis.

Specific causes of upper GI bleeding and their symptoms

●Peptic ulcer: Upper abdominal pain

●Esophageal ulcer: Odynophagia, gastroesophageal reflux, dysphagia

●Mallory-Weiss tear: Emesis, retching, or coughing prior to hematemesis

●Variceal hemorrhage or portal hypertensive gastropathy: Jaundice, abdominal distention (ascites)

●Malignancy: Dysphagia, early satiety, involuntary weight loss, cachexia

Physical examination: Symptoms: light-headedness, shortness of breath, abdominal pain. Signs of hypovolemia (hypotension, tachycardia), blood in the stool.

Q: What is the diagnostic modality of choice for acute upper GI bleeding: Upper endoscopy.

Q: Can you order upper GI barium studies in the setting of acute upper GI bleeding? No, they are contraindicated.

Q: What do you suspect in a patient with hematemesis, severe abdominal pain, rebound tenderness and guarding? Perforation.

Treatment includes Fluid repletion with IV fluids, transfuse packed red cells, endoscopy, IV proton pump inhibitors, prokinetics (metoclopramide, erythromycin), antibiotics for patients with cirrhosis, IV octreotide to reduce portal blood pressure in variceal bleeding, intra-arterial embolization, Transvenous Intrahepatic portosystemic shunts (TIPS)