Upper and Lower Gastrointestinal
Bleeding
Said Al Harthy
ENP, Academic
Coordinator
22/12/2020
Learning Objectives
At the end of this session, participants will be able to:
1. Identify the symptoms and possible underlying causes of upper
and lower GI bleeds.
2. Discuss different treatment options for upper and lower GI
bleeds.
Anatomy of
the
digestive
system
Anatomy of the Portal System
Definition
● Gastrointestinal (GI) bleeding refers to any bleeding that
starts in the gastrointestinal tract
● Divided into upper GI bleeding, which includes the
esophagus, stomach, and duodenum
● Lower GI bleeding includes much of the small intestine,
large intestine or bowels, rectum, and anus
● GI Bleeding is
classified as
upper or lower
based on
whether the
source is above
or below the
Ligament of
Treitz.
Major Presenting Factors of Upper GI
Bleed
● Hematemesis (either red blood or coffee-ground
emesis) suggests bleeding proximal to the ligament
of Treitz
● The majority of melena (black, tarry stool) originates
proximal to the ligament of Treitz (90 percent)
● It may also originate from the small bowel or right
colon.
● Hematochezia (red or maroon blood in the stool)
may occur in cases of upper GI bleeding although
seen in lower GI bleeds more commonly
Acute Upper GI Bleed
Sudden, severe bleeding is called acute bleeding. If acute
bleeding occurs, symptoms may include
● weakness
● dizziness or faintness
● shortness of breath
● crampy abdominal pain
● diarrhea
● paleness
Gastric erosions
Minor ulceration of the
gastric mucosa
● If an ulceration extends
deeper than this layer, it
is called a gastric ulcer.
● (aspirin and NSAID) are
most likely the cause
Peptic ulcer disease:
●Infectious:
Helicobacter pylori,
Cytomegalovirus, Herpes simplex
virus
●Drug induced: Aspirin Nonsteroidal
anti-inflammatory drugs
●Stress-induced ulcer
Perforated Gastric ulcer:
● Constant mild to severe pain
● H/O intermittent pain after food
● Orthostatic hypotension
● Paleness
● Rigidity
● Tenderness
● Decreased/absent bowel sounds
Stress gastritis
(stress ulcer)
● Acute stress gastritis is a disease process characterized
by diffuse superficial mucosal erosions that appear as
discrete areas of erythema
It is occurs in pt. with:
● Head injuries called Cushing ulcer
● Burn injuries called Curling ulcer.
● Major surgery
● Multiple trauma
Esophageal varices:
● Variceal bleeding is one of the
most alarming life-threatening
complications of portal
hypertension.
Portal hypertensive
gastropathy
● Refers to changes in the mucosa of
the stomach in patients with portal
hypertension.
● These changes in the mucosa
include fragility of the mucosa and
the presence of unusual blood
vessels at the surface.
● Mosaic or "snake-skin"
appearance
Gastric Carcinoma:
Mallory-Weiss syndrome
● Refers to bleeding from linear
mucosal tear at the
gastroesophageal junction .
● Usually caused by sever retching
(alcohol intoxication), coughing or
vomiting.
Dieulafoy‘s disease
● Is a vascular malformation of the
proximal stomach, usually within 6
cm of the gastroesophageal junction
along the lesser curvature of the
stomach.
● It can occur anywhere along the GI
tract.
● Because of the large size of the
vessel, bleeding can be massive
Endoscopic appearance of non-bleeding
Dieulafoy’s lesion
Management:
1. Initial Management:
Stabilizing the patient by:
-Check the Air way, Breathing & Circulation.
-establish two large-pore Ivs and administer 1-2 liters of
normal saline
-CBC, LFT,PT,PTT, U&E, cross-matching
-NG tube to evacuate stomach and monitor further
bleeding.
Schedule on endoscopy.
II. Later Management
Peptic ulcer:
Most pt with bleeding peptic ulcer can be successfully
managed by medical means alone.
H2 blockers eg.cimetidine
PPI eg.omeprazole.
-must always biopsy gastric ulcer to rule out cancer,but
duodenal ulcers are almost never malignant.
Endoscopic Therapy:
-Injection of epinephrine, epinephrine plus sclerosing
agent, or cautery.
Surgical Treatment criteria:
● Persistant bleeding or rebleeding.
● Vissible vessel at the ulcer base.
● Pt acquired >6 units of blood.
Esophageal varices:
1-Endoscopic sclerotherapy:
1-3 mL of sclerosant solution into the lumen, causing it to
become thrombosed.
Usually repeated within 48h,then once or twice again at
weekly intervals.
2-Vasopressin:
portal blood flow and pressure by constrict splanchnic
arterioles.
3- Octreotide/somatostatin:
Same effect as vasopressin but without
significant side effects.
4-Ballon tamponade:
Inflated to compress
bleeding varices.
Complications:
aspiration pneumonia
Esophageal rupture.
Sengstaken-Blakemore tube
Mallory weiss syndrome:
-about 90% of pt, bleeding stop spontaneously
after ice-water lavage of stomach. If still bleeding
endoscopic therapy (Electrocautery)
Surgical repair of the tear
(high gastrotomy & under-running with absorbable
suture)
Dieulafoy’s Disease:
● Treated by Endoscopic sclerotherapy or
surgically by local excision.
Major Presenting Factors and
Symptoms of Lower GI Bleed
● Black or tarry stool
● Dark blood mixed with stool
● Stool mixed or coated with bright red blood
Major Presenting Factors and
Symptoms of Lower GI Bleed
● Diverticular disease. This disease is caused by
diverticula—pouches in the colon wall.
● Colitis. Infections, diseases such as Crohn's disease, lack of blood
flow to the colon, and radiation can cause colitis—inflammation of
the colon.
● Hemorrhoids or fissures. Hemorrhoids are enlarged veins in the
anus or rectum that can rupture and bleed. Fissures, or ulcers, are
cuts or tears in the anal area.
● Angiodysplasia. Aging causes angiodysplasia—abnormalities in
the blood vessels of the intestine.
● Polyps or cancer. Benign growths or polyps in the colon are
common and may lead to cancer. Colorectal cancer is the third most
common cancer in the United States and often causes occult
bleeding
MEDICAL HISTORY
• Details about the bleeding :
📫 Amount
📫 Color
📫 Duration
📫 Nature :
A. Mixed with stool
B. Streaked on the stool
C. On the underwear or toilet paper
Diverticulitis
● Results from progressive injury
to the artery supplying that
segment
Clinical presentation
● Abdominal pain
● Diarrhea
● Fever
● Tender to palpation at the left
lower quadrant
● Mild distention
Colitis
●Inflammation of the inner lining
of the colon.
Causes:
●Ischemic colitis
●Infection
●Loss of blood supply to the
colon (ischemia)
●Inflammatory: (Crohn's disease,
ulcerative colitis)
●Allergic reactions
Hemorrhoids
● External hemorrhoids arise from
the inferior hemorrhoidal plexus
and are located beneath the
dentate line. They are covered
with squamous epithelium
● Internal hemorrhoids arise from
the superior hemorrhoidal
cushion
● extreme itching around the anus
● irritation and pain around the anus
● itchy or painful lump or swelling near the anus
● fecal leakage
● painful bowel movements
● blood on tissue after having a bowel movement
Anal Fissures
● Tear in the lining of the anal
canal distal to the dentate line,
which most commonly occurs in
the posterior midline
● The majority of anal fissures are
caused by local trauma to the
anal canal, such as after
passage of hard stool
● Continued pain and chronicity
References
● 1. Gastrointestinal bleeding. MedlinePlus. National Institutes of Health. January
2011. Available at http://www.nlm.nih.gov/medlineplus/ency/article/003133.htm.
● 2. Bleeding in the Digestive Tract. National Digestive Diseases Information Clearinghouse.
January 2010. Available at http://digestive.niddk.nih.gov/ddiseases/pubs/bleeding/.
● 3. Gastrointestinal Bleeding. Mayo Clinic. Accessed August 2011. Available at
http://www.mayoclinic.org/gastrointestinal-bleeding/diagnosis.html.
● 4. Manning-Dimmitt LL, Dimmitt SG, Wilson GR. Diagnosis of Gastrointestinal Bleeding in
Adults. American Family Physician. American Academy of Family Physicians. April 2005.
Available at http://www.aafp.org/afp/2005/0401/p1339.html.
● 5. Krumberger JM. How to Manage an Upper GI Bleed. Modern Medicine. March 2005.
Available at
http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=150046.
● 6. Barnert J, Messmann H. Diagnosis and management of lower gastrointestinal bleeding.
Nature Reviews. Medscape CME. November 2009. Available at
http://www.nature.com/nrgastro/journal/v6/n11/full/nrgastro.2009.167.html
