Gastrointestinal Bleeding

GIB: Overview & Initial Rx - Spotting the Source

• Types: UGIB (proximal to Lig. of Treitz), LGIB (distal). Overt (visible) vs. Occult (FOBT+).
• Initial Rx (ABCDE):
  • Assess hemodynamics (Shock Index: $HR/SBP$ > 0.9 indicates shock).
  • Secure airway; 2 large-bore IV cannulas.
  • Fluid resuscitation: Crystalloids. Blood if Hb < 7 g/dL (or < 9 g/dL in CAD).
  • Correct coagulopathy (FFP, Vit K).
• Spotting Source:
  • History (NSAIDs, EtOH), exam.
  • NG lavage (UGIB), proctoscopy (fresh PR bleed).
  • Endoscopy: EGD for UGIB, Colonoscopy for LGIB.

⭐ Most common cause of significant UGIB is peptic ulcer disease.

UGIB: Causes & Management - Above Treitz Terrors

Bleeding proximal to Ligament of Treitz.

Causes:

• Non-Variceal (80%): PUD (H. pylori, NSAIDs), Mallory-Weiss, Erosions, Dieulafoy's.
• Variceal (20%): Esophageal/Gastric varices (portal HTN). 📌 Causes: Mallory, Esophagitis, Dieulafoy, Inflammation (gastritis), Cancer, Ulcer, Varices. (MEDIC UV)

Management:

• Resuscitation: ABCs, IV fluids, blood (Hb < 7 g/dL). PPI (non-variceal), Octreotide + Abx (variceal).
• Risk Stratify: Glasgow-Blatchford (GBS > 0 high risk), Rockall.
• Endoscopy (OGD): Within 24h. Diagnose & treat.
  • Non-variceal: Forrest class. Clips, thermal, adrenaline.
  • Variceal: Banding, sclerotherapy.
• Post-Endo: PPI, H. pylori eradication. beta-blockers (varices). TIPS if refractory.

⭐ Forrest Ia (spurting arterial bleed) has ~55% rebleed risk without endoscopic therapy.

LGIB: Causes & Management - Below Treitz Troubles

• Bleeding distal to Ligament of Treitz.
• Common Causes:
  • Diverticulosis: Most common cause of massive LGIB; typically painless, arterial bleed.
  • Angiodysplasia: Vascular ectasias, common in elderly, right colon; often occult or recurrent.
  • Colitis: IBD, ischemic, infectious; usually associated with pain, bloody diarrhea.
  • Neoplasms/Polyps: Can cause chronic occult or acute frank bleeding.
  • Anorectal: Hemorrhoids, fissures; bright red blood on toilet paper (BRBPR).
• Diagnosis:
  • Initial: Exclude UGIB if suspected.
  • Stable patients: Colonoscopy (diagnostic & therapeutic).
  • Active/Massive bleed: CTA (preferred if bleed >0.3-0.5 mL/min) or Tagged RBC scan (detects bleed >0.1-0.5 mL/min).
• Management:
  • Resuscitation: ABCs, 2 large-bore IV lines, fluids, blood products.
  • Therapeutic Colonoscopy: Clips, thermal coagulation, epinephrine injection.
  • Angiographic embolization: For active bleeding identified on CTA/RBC scan.
  • Surgery: Segmental resection or subtotal colectomy for refractory/unlocalized severe bleeding.

⭐ Diverticulosis is the most common cause of major LGIB. Bleeding stops spontaneously in ~80% of cases, but recurrence is common (20-40%).

OGIB & Small Bowel - Elusive Escapes

• Obscure GI Bleed (OGIB): Persistent/recurrent bleeding despite negative UGI endoscopy & colonoscopy.
  • Overt: Melena, hematochezia.
  • Occult: FOBT positive, iron deficiency anemia.
• Small bowel is the source in ~75% of OGIB cases.
• Key Investigations:
  • Video Capsule Endoscopy (VCE): First-line for suspected small bowel source.

    ⭐ VCE boasts the highest diagnostic yield for detecting small bowel bleeding causes.

  • Device-Assisted Enteroscopy (DAE): For diagnosis & intervention.
  • CT/MR Enterography; Angiography for active bleed.
• Common Causes: Angiodysplasia (most common), tumors, NSAID enteropathy, Crohn's.

High‑Yield Points - ⚡ Biggest Takeaways

• UGIB is more common; LGIB often from diverticulosis or angiodysplasia.
• Peptic ulcer disease is the leading cause of UGIB.
• Initial management for severe bleeding: Resuscitation (fluids, blood products).
• Early endoscopy (within 24h) is key for UGIB diagnosis & therapy.
• Rockall and Glasgow-Blatchford scores assess risk in UGIB.
• Variceal bleeds: manage with octreotide, antibiotics, & EVL.
• Massive LGIB may need angiography/embolization or surgery.