Gastrointestinal Bleeding

Overview & Initial Approach - Spot the Source

• GIB: Bleeding from GI tract.
  • UGIB: Proximal to Ligament of Treitz (e.g., varices, PUD).
  • LGIB: Distal to Ligament of Treitz (e.g., Meckel's, intussusception).
• Initial Approach:
  • ABCDE: Secure airway, IV access (2 large bore).
  • Resuscitation: Crystalloids; blood if Hb < 7 g/dL or shock.
  • History (medications, liver disease), exam (PR).
• Spot the Source:
  • UGIB: Hematemesis, melena. NG aspirate: blood/coffee grounds.
  • LGIB: Hematochezia (fresh/maroon blood).

⭐ In neonates, perform Apt-Downey test on bloody stools/vomitus to differentiate maternal vs. fetal blood.

Upper GI Bleeding - Gullet Gushes

• Bleeding proximal to Ligament of Treitz.
• Presentation: Hematemesis (fresh red/coffee-ground), melena. Hematochezia in massive bleeds.
• Common Causes:
  • Adults: Peptic Ulcer Disease (PUD) (>50%), varices, esophagitis, Mallory-Weiss tear.
  • Children: Esophagitis, PUD, varices (portal HTN), gastritis.
• Initial Management:
  • Secure ABCs; 2 large-bore IV lines; IV fluids (crystalloids, blood).
  • IV Proton Pump Inhibitors (PPIs).
  • Early endoscopy (diagnostic & therapeutic) within 24 hrs.
  • Octreotide for suspected variceal bleed.
  • Risk stratification: Rockall / Glasgow-Blatchford score.

⭐ Most common cause of significant upper GI bleeding is Peptic Ulcer Disease (PUD).

Lower GI Bleeding - Colon Carnage

• Bleeding distal to Ligament of Treitz. Presentation: hematochezia (BRBPR), maroon stools.
• Adult Causes:
  • Diverticulosis: Commonest cause, typically painless, massive bleeding.
  • Angiodysplasia: Painless arteriovenous malformations (AVMs), common in elderly.
  • Colitis: Inflammatory Bowel Disease (IBD), ischemic, infectious (often painful).
  • Neoplasms: Colorectal cancer (CRC), polyps (can be occult or frank bleeding).
  • Anorectal: Hemorrhoids, fissures (bright red blood on toilet paper/surface).
• Pediatric Causes:
  • Meckel's diverticulum (painless, brick-red stools).
  • Intussusception (currant jelly stool, pain).
• Diagnosis & Management Pathway:
  • Hemodynamic stabilization: ABCs, IV fluids, blood transfusion if Hb < 7 g/dL.
  • Exclude Upper GI Bleed (e.g., nasogastric lavage if diagnosis unclear).
  • Colonoscopy: Gold standard for diagnosis and potential therapy.
  • If severe/obscure bleeding: CT Angiography (CTA), tagged RBC scan, then angioembolization or surgery.

⭐ Diverticulosis is the most common cause of significant lower GI bleeding in adults, typically presenting as acute, painless, large-volume hematochezia.

Diagnostic Tools & Management - Scope & Stop

• Stabilize: ABCs, IV access (2 large-bore), fluids, blood (Hb <7 g/dL or active bleed).
• Labs: CBC, coags (PT/INR, PTT), LFTs, RFTs, type & crossmatch.
• Endoscopy (Scope):
  • EGD (UGIB): Within 24h. Diagnostic & therapeutic.
  • Colonoscopy (LGIB): If stable + prep. CT Angio for brisk bleed.
  • Capsule/Enteroscopy: Obscure GIB.
• Hemostasis (Stop):
  • Endo-Therapy: Injection (adrenaline), thermal (cautery/APC), mechanical (clips/bands).
  • Target: High-risk stigmata (Forrest Ia-IIb).
• Post-Scope/Failure: PPIs (UGIB). Repeat scope, IR (embolization), or surgery if refractory.

  ⭐ Active variceal bleeding: Endoscopic variceal ligation (EVL) is first-line therapy.

High‑Yield Points - ⚡ Biggest Takeaways

• Anal fissure is the most common cause of minor lower GI bleeding in infants.
• Suspect Meckel's diverticulum with painless, profuse rectal bleeding in young children.
• Intussusception classically presents with currant jelly stool and colicky abdominal pain.
• Neonatal hematemesis: Consider swallowed maternal blood; confirm with Apt-Downey test.
• Esophageal varices from portal hypertension cause severe upper GI bleeds.
• Infectious colitis (e.g., Shigella) causes bloody diarrhea, fever, and abdominal pain.