Gastrointestinal Bleeding: Causes, Symptoms, and Treatment

Gastrointestinal Bleeding: Causes, Symptoms, and Treatment

1. Introduction:

Gastrointestinal bleeding (GIB) is a condition where blood leaks from blood vessels in the gastrointestinal tract, manifesting as vomiting blood or passing blood in stool. This is a medical/surgical emergency requiring prompt management to prevent life-threatening complications.

2. Classification:

• Upper GIB: Bleeding originates from the gastrointestinal tract above the Treitz ligament (the junction of the duodenum and jejunum).

• Small Bowel Bleeding (Occult Bleeding): Blood escapes from the small intestine, often not visible to the naked eye. Diagnosis relies on laboratory tests.

• Lower GIB: Bleeding occurs in the large intestine (colon).

3. Severity of GIB:

The severity of GIB is assessed based on multiple factors, including:

• Pulse: Heart rate.

• Blood Pressure (BP): Pressure of blood in the arteries.

• Blood Loss: Amount of blood lost due to bleeding.

• Systemic Symptoms: Dizziness, reduced urine output, pale skin, pale mucous membranes, etc.

• Hct: Hematocrit (proportion of red blood cells in the blood).

• RBC: Red blood cell count.

4. Moderate GIB:

• Pulse: 100-120 beats/minute.

• Systolic BP: 80-90 mmHg.

• Blood Loss: 10%-30% (500-1500ml).

• Systemic Symptoms: Dizziness, reduced urine output, pale skin, pale mucous membranes.

• Hct: 20-30%.

• RBC: 2-3 million/mm3.

5. Early GIB Assessment:

In the initial hours, GIB assessment should focus on:

• Pulse: Heart rate.

• Blood Pressure: Blood pressure.

• Level of Consciousness: Patient’s awareness and responsiveness.

• Vomiting and Stool Volume: These may not accurately reflect blood loss unless visible blood is witnessed.

6. Principles of GIB Management:

• Medical Resuscitation:

• General Measures: Head elevation, oxygen administration, fasting.

• Volume Replenishment: Administration of fluids and blood products.

• Medications: Hemostatic agents, anti-ulcer medications, antibiotics, etc.

• Diagnostic and Therapeutic Endoscopy: Identification of bleeding location and cause, followed by endoscopic hemostasis.

• Referral: Consideration for interventional radiology or surgery.

7. Volume Replenishment in GIB:

• Fundamental Measure: Establish intravenous access as early as possible.

• Solutions: Lactated Ringer’s (LR), 0.9% NaCl, 5% Dextrose.

• Avoid Hypertonic Solutions: 10-30% Dextrose.

• Blood Transfusion: In cases of severe GIB.

8. Objectives of Fluid Administration:

• Maintain Vital Signs: Prevent tachycardia, hypotension, and collapse.

• Avoid Excessive BP Increase: This can trigger re-bleeding.

• Cautions: Heart failure, kidney failure, hypertension, chronic anemia.

9. Blood Transfusion:

• Transfusion of Missing Components: Priority given to packed red blood cells over whole blood.

• Severe GIB: Blood transfusion should be initiated immediately, even without complete hematological test results.

• High-Risk Patients (Over 65 years old, coronary artery disease): Transfuse when Hb < 9g/dl, but not exceeding 10g/dl.

• Low-Risk Patients: Hb < 7g/dl.

10. Fresh Frozen Plasma Transfusion:

• Fibrinogen < 1g/L or INR > 1.5.

• Transfuse 10-15ml/kg.

• Consider Overloading in Patients with Pre-existing Heart Disease or Elderly Individuals.

11. Platelet Transfusion:

• Platelet count below 50,000/mm3 and patients with ongoing bleeding.

12. GIB due to Portal Hypertension:

• Leading Cause of Death in Patients with Cirrhosis.

• Some Patients Experience Esophageal Variceal Rupture Before Cirrhosis Development.

• 30% of Patients with Esophageal Varices Develop GIB.

• GIB Often Occurs Within 1 Year of Esophageal Variceal Diagnosis.

13. GIB due to Esophageal Varices:

• Mortality Rate Approximately 20% after 6 Weeks.

• 80% of Patients Have a Risk of Re-bleeding Within 1 Year.

14. Grading of Esophageal Varices:

• Grade I: < 5mm, straight, only seen in the distal esophagus.

• Grade II: 5-10mm, tortuous, extending to the mid-esophagus.

• Grade III: > 10mm, occupying most of the esophageal lumen.

15. Grading of Gastric Varices:

• Grade I: < 5mm, resembling gastric mucosa.

• Grade II: 5-10mm, including solitary pseudo-polyps.

• Grade III: > 10mm, multiple pseudo-polyps.

16. Management of GIB due to Esophageal Varices:

• Ensure ABC (Airway, Breathing, Circulation).

• Hemostasis Treatment: Anti-ulcer medications, endoscopic banding, balloon tamponade.

• Other Treatment: Prophylactic antibiotics for infection prevention, prevention of hepatic encephalopathy, PPI after endoscopic treatment.

17. Volume Replenishment in GIB due to Esophageal Varices:

• Establish Two Intravenous Lines: Separate blood line if needed.

• Immediate Blood Request in Severe GIB.

• Avoid Excessive Blood Transfusion: May increase portal hypertension, increasing re-bleeding and mortality rates.

18. GIB due to Esophageal Variceal Rupture:

• When Coagulation Factors are Abnormal: Adjust coagulation factors, but do not delay endoscopic intervention.

19. Hemostasis Strategies for Pre-esophageal Variceal GIB:

• Anti-ulcer Medications + Endoscopic Esophageal Variceal Banding.

• Endoscopic Sclerotherapy.

• Balloon Tamponade.

20. Anti-Ulcer Medications:

• Mechanism: Constriction of visceral blood vessels, reducing blood flow and thus portal hypertension.

• First-Line Treatment: To reduce portal hypertension (control bleeding and re-bleeding).

21. Indications for Anti-Ulcer Medications:

• Immediately when GIB due to portal hypertension is suspected.

22. Effectiveness of Anti-Ulcer Medications:

• Temporary Hemostasis Rate of 80%.

• Long-term Use for 3-5 Days After Diagnosis.

23. Types of Anti-Ulcer Medications:

• Terlipressin.

• Somatostatin.

• Ocreotide.

24. Terlipressin Dosage:

• 2mg IV/4 hours.

• May be reduced to 1mg/4 hours after bleeding control.

25. Somatostatin Dosage:

• Bolus 250 ug IV.

• Infusion 250 ug/hour.

26. Ocreotide Dosage:

• Bolus 50 ug.

• Infusion 50 ug/hour.

27. Ocreotide Effectiveness:

• Shorter-lasting effect compared to Terlipressin and Somatostatin.

• Effective as an adjunct after endoscopic hemostasis.

28. Endoscopic Hemostasis in GIB due to Esophageal Varices:

• Within 12 Hours.

• As Early as Possible.

• After Hemodynamic Stabilization.

• Ideally after Blood Transfusion.

• Do not wait for coagulation factor correction.

29. Signs of Ongoing Bleeding During Endoscopy:

• Visible bleeding from varices.

• Blood clots adhering to the vein wall.

• Presence of nipple sign (white spot due to platelet adherence to the vein wall).

30. Endoscopic Hemostasis Treatment:

• EVL (Endoscopic Variceal Ligation) >>>>> Sclerotherapy.

31. Endoscopic Hemostasis in Gastric Varices:

• Injection of cyanoacrylate glue.

• GEV1 Specifically: Glue > EVL.

32. GEV1, GEV2, IGV1:

• GEV1: Gastric varices on the lesser curvature of the stomach.

• GEV2: Gastric varices in the gastric fundus.

• IGV1: Solitary gastric varices.

33. Balloon Tamponade for Hemostasis:

• Temporary Hemostasis Effectiveness > 80% of Cases.

• Numerous Complications (Aspiration, displacement, esophageal rupture).

• Use only in cases of brisk bleeding, for temporary hemostasis while awaiting other methods.

• No longer than 24 hours.

34. Types of Tamponade Balloons:

• Blakemore Balloon.

• Linton-Nachlas Balloon.

35. Characteristics of the Blakemore Balloon:

• Two Balloons: Esophageal balloon (80ml) and gastric balloon (140ml).

36. Linton Balloon:

• Single Balloon with a Capacity of 350ml.

37. Balloon Inflation Pressure:

• 35-45 mmHg.

• Monitor every 3 hours.

38. Absolute Contraindications for Balloon Tamponade:

• Known Esophageal Stricture.

• Recent Surgery in the Cardioesophageal Region.

39. Relative Contraindications for Balloon Tamponade:

• Respiratory Failure.

• Heart Failure, Arrhythmias.

• Hiatal Hernia.

• Uncertainty about Variceal GIB.

• Esophageal Ulcerations due to Prior Endoscopic Treatment (Use only the gastric balloon, not the esophageal balloon).

40. Monitoring During Balloon Tamponade:

• Check balloon pressure every 3 hours.

• Deflate the esophageal balloon for 5 minutes every 6 hours.

41. Hemostasis After 24 Hours of Balloon Tamponade:

• Deflate the esophageal balloon, leave in place for 6-12 hours.

• If stable, deflate the gastric balloon, leave in place for 6-12 hours.

• If stable, remove the balloon.

• If re-bleeding, maintain the balloon for another 24 hours.

42. Other Treatments for GIB due to Esophageal Varices:

• Prophylactic Antibiotics.

• Hepatic Encephalopathy Prevention.

43. Prophylactic Antibiotics:

• Administer for 7 days:

• Moxifloxacin 400mg x2.

• Ciprofloxacin 400mg x2.

• Ceftriaxone 1g (if Child-Pugh B/C).

44. Hepatic Encephalopathy Prevention:

• Lactolose: 10g/packet x3.

• Adjust to ensure bowel movements 2-3 times daily.

45. Management of GIB Not Due to Esophageal Varices:

• Ensure ABC.

• Volume Replenishment.

• Medical Treatment.

• Endoscopic Treatment.

46. Medical Treatment for GIB Not Due to Esophageal Varices:

• Based on:

• Acid pH’s Influence on Platelet Aggregation.

• Gastric Juice’s Effect on Clot Dissolution.

47. Role of Acid in Hemostasis:

• Inhibits Clot Formation.

• Promotes Clot Dissolution.

• Weakens the Protective Mucus/Bicarbonate Barrier.

48. Use of Acid Inhibitors Before Endoscopy:

• PPI >>>>> antiH2.

• Timing: Administer immediately upon admission if endoscopic intervention is not considered optimal.

• Type: Omeprazole, Esomeprazole, Pantoprazole, Lansoprazole.

• Route: IV >>>> oral.

• Dosage: Bolus 80mg, continuous infusion 8mg/hour.

• Re-evaluate after endoscopic findings.

49. Forrest Classification:

• Forrest Ia: Active spurting blood (re-bleeding risk 55%).

• Forrest Ib: Oozing blood (high re-bleeding risk).

• Forrest IIa: Visible vessel (re-bleeding risk 43%).

• Forrest IIb: Adherent clot (re-bleeding risk 22%).

• Forrest IIc: Hematin adherent to ulcer base (re-bleeding risk 10%).

• Forrest III: No recent bleeding signs, ulcer base covered by fibrin (re-bleeding risk 5%).

50. Assessing Re-bleeding Risk According to Forrest:

• High Risk: Ia, Ib, IIa, IIb.

• Low Risk: IIc, III.

51. PPI Use After Endoscopy Based on Forrest:

• High Risk: Endoscopic treatment, high-dose IV PPI (bolus followed by 72-hour continuous infusion).

• Low Risk: No endoscopic treatment, oral PPI.

52. Endoscopic Intervention in GIB Not Due to Esophageal Variceal Rupture:

• 12-24 Hours.

• Exceptions:

• Patients with significant vomiting and hemodynamic instability: Endoscopy as soon as possible after stabilization.

• Patients with cardiovascular or respiratory disease: Can be delayed when pulse, temperature, BP, and SaO2 are stable.

53. Endoscopic Techniques in GIB Not Due to Esophageal Variceal Rupture:

• Hemostatic Injection.

• Thermal Ablation: Heat, APC, Laser.

• Mechanical Methods: Clips, banding.

• New: Hemostatic powder application.

54. Hemostatic Injection During Endoscopy:

• Local Pressure: Diluted adrenaline.

• Sclerotherapy, Thrombus Formation: Polidocanol, Ethanolamine.

• Tissue Glue: Cyanoacrylate, Thrombin, fibrin.

55. Monitoring for Re-bleeding:

• Glasgow-Blatchford Score: Higher score, higher risk.

• High Forrest Scores.

• Endoscopic Features.

56. Endoscopic Features Indicating High Re-bleeding Risk:

• Gastric Ulcers Along the Lesser Curvature (Near the Left Gastric Artery).

• Posterior Duodenal Ulcers (Gastroduodenal Artery).

• Large Ulcers (1-2 cm) (Larger blood vessels in the ulcer base).

57. Management of Re-bleeding:

• Continued Medical Resuscitation.

• Repeat Endoscopy: Usually considered first.

58. Re-bleeding or Re-bleeding During Repeat Endoscopy:

• Interventional Radiology.

• Surgery (Interventional radiology is less invasive, consider first).

59. Interventional Radiology in GIB Not Due to Esophageal Variceal Rupture (Second Bleeding Episode):

• Successful Hemostasis in 52-98% of Cases.

• Reduces Re-bleeding Rate by 12-20%.

60. Absolute Indications for Surgery:

• Re-bleeding with Perforation of a Hollow Organ.

• Re-bleeding with Shock, Precluding Endoscopic or Interventional Radiological Intervention.

• Failure of Interventional Radiological Intervention.

61. Relative Indications for Surgery:

• Rare Blood Type.

• Elderly Patients Unable to Tolerate Prolonged Resuscitation.

• Large Volume of Volume Replacement.

• Multiple Episodes of Hypotension.

62. Blood Loss Severity:

• Grade I: Less than 1L (< 15%).

• Grade II: 1-1.5L (15-30%).

• Grade III: 1.5-2L (30-40%).

• Grade IV: Greater than 2L (> 40%).

63. Complications of GIB:

• Acute Kidney Injury.

• Hemorrhagic Shock.

• Multi-Organ Failure.

• Death.

64. Approach to GIB Patients:

• 7 Key Questions:

• Is there bleeding?

• Where is the bleeding located?

• How severe is the bleeding?

• What is the cause of bleeding?

• What is the bleeding progression?

• Are there any complications?

• What are the associated risk factors?

65. Blood Color Based on Bleeding Location:

• The closer to the point of origin, the brighter the red color, with less mixing with digestive fluids and feces.

• Esophagus: Bright red, minimal fecal or gastric fluid mixing.

• Stomach: Mixed with food and gastric juice, color altered by gastric juice.

• Colon: Redder from the descending colon and left colon, often darker in the right colon.

• Blood from the Anus/Rectum: Bright red blood, accompanied by yellow stool.

66. Upper GIB with Red Stool:

• Patients must have suggestive signs of severe gastrointestinal bleeding.

67. Orthostatic Hypotension:

• Patient shifts from lying down to sitting with legs hanging, then stands up.

• Systolic BP drop > 20 mmHg.

• Diastolic BP drop > 10 mmHg.

68. Tilt Test:

• Patient shifts from lying down to sitting with legs hanging.

• Systolic BP drop > 10 mmHg.

• Heart rate increases by 20 beats.

69. Pulse and BP Assessment Based on Blood Loss Severity:

• Pulse: 100-120-140.

• Blood Pressure: Normal – Orthostatic hypotension – Orthostatic hypotension in lying position – Unmeasurable BP.

70. Assessing Pulse Pressure, Respiration Rate, Urine Output, and Level of Consciousness Based on Blood Loss Severity:

• Pulse Pressure: Normal or increased – Slightly decreased – Slightly decreased, difficult to palpate.

• Respiration Rate: Normal – Slightly increased – 30-40.

• Urine Output: 30 – 20 – 5 – Anuria.

• Level of Consciousness: Alert – Anxious – Confused – Comatose.

Note: This information is for informational purposes only and does not substitute for professional medical advice. If you experience any health concerns, please consult a doctor for prompt diagnosis and treatment.