Gastrointestinal bleeding

Background

• Loss of blood from the GI tract distal to the ligament of Treitz
• Upper GI bleeds are most common source for blood detected in the lower GI system
• 80% of lower GI bleeding will resolve spontaneously
• Cause for bleeding is found in <50% of cases

Diagnosis

History

• Hematochezia
  • Bright red or maroon-colored bleeding that comes from the rectum
  • Usually represents lower GI bleeding
  • May represent UGIB if bleeding is brisk
    • Usually accompanied by hematemesis and hemodynamic instability
• Melena
  • Usually represents bleeding from upper GI source
  • May represent bleeding from lower GI source due to slow bleeding

DDX

1. Upper GI bleed
2. Diverticular disease
   1. Painless bleeding
   2. Up to 90% of episodes resolve spontaneously
   3. Can result in massive hemorrhage
3. Vascular ectasia
   1. Angiodysplasia, AVM
4. Inflammatory bowel disease
5. Colitis
   1. Infectious
   2. Ischemic
      1. 90% of cases occur in age >70yo
      2. Colon is predisposed to ischemia due to poor vascular ciculation, high bacterial count
      3. Causes: aneurysmal rupture, vasculitis, hypercoagulable, CV insult, IBS, slow motility
      4. Most cases resolve on own; 20% of cases requires surgical intervention
6. Mesenteric Ischemia
   1. Medical emergency that often leads to bowel necrosis
   2. Causes: thrombosis/embolism of SMA, mesenteric vein thrombosis, low arterial flow
   3. Associated w/ A fib, CHF, MI, age >60yo
   4. CT only 64% Sn, angiography is imaging study of choice
7. Meckel Diverticulum
8. Malignancy / polyps
9. Hemorrhoids
   1. Massive hemorrhage is unusual
10. Rectal ulcer
11. Foreign body
12. Rectal ulcer (HIV, syphilis, STIs)
13. Anal fissure

Consider

1. Proctoscopy (22cm from anal verge)
2. Sigmoidoscopy (60cm from anal verge)
3. Angiography (requries arterial bledding >0.5cc/min)
4. CT angio

Disposition

Rockall score

Home (very low risk)

1. No comorbid dz
2. Normal vitals
3. Norma/trace pos guiac
4. Normal/near-normal Hb
5. Home support
6. F/U within 24hrs

Ward/Stable (low risk)

1. Age <60
2. Initial SBP >100
3. Normal vitals x 1hr
4. No transfusion req
5. No major comorbid
6. No liver dz

ICU

1. Normal or dec Hct
2. Blood in NG doesn't clear
3. SBP<100, HR>100
4. Gauaic +/- stool

False Positive Guaiac

1. Red fruits and meats
   1. (Bananas, turnips, broccoli)
2. Methylene blue
3. Chlorophyll
4. Iodide
5. Cupric sulfate
6. Bromide
7. Iron (causes GI bleed by irritation)

Source

• Tintinalli