Gastrointestinal Bleeding Clinical Guide
Introduction
Gastrointestinal (GI) bleeding is blood loss originating anywhere from the esophagus to the rectum. Presentations range from occult iron-deficiency anemia to life-threatening hemorrhage. Early risk stratification and timely endoscopic or angiographic therapy reduce morbidity and mortality. This guide summarizes classification, common causes, initial stabilization, diagnostics, and management pearls for clinicians.
Contents
Classification and Typical Presentation
| Category | Anatomic definition | Usual presentation |
|—|—|—|
| Upper GI bleeding (UGIB) | Proximal to the ligament of Treitz | Hematemesis, coffee-ground emesis, melena; brisk bleeds may cause hematochezia |
| Middle (small bowel) | Jejunum to ileum | Occult or overt bleeding after negative EGD/colonoscopy; melena or maroon stools |
| Lower GI bleeding (LGIB) | Distal to ileocecal valve (colon, rectum, anus) | Hematochezia, maroon stools; melena possible with right-sided sources |
Hemodynamic instability (tachycardia, hypotension, syncope) warrants immediate resuscitation and urgent intervention planning.
Common Etiologies
Upper GI
- Peptic ulcer disease (NSAIDs, H. pylori)
- Esophageal/gastric varices due to portal hypertension
- Erosive gastritis/duodenitis, reflux esophagitis
- Mallory–Weiss tear (post‑retching)
- Malignancy (esophagus, stomach)
- Dieulafoy lesion; angiodysplasia; hemobilia
Small Bowel
- Angiodysplasia, NSAID enteropathy
- Meckel diverticulum (younger patients)
- Small-bowel tumors; Crohn disease
Lower GI
- Diverticulosis (common, often painless, brisk)
- Angiodysplasia (especially elderly, aortic stenosis/CKD)
- Hemorrhoids, anal fissures (minor bleeding)
- Colitis (infectious, ischemic, inflammatory)
- Colorectal neoplasia/polyps
Initial Assessment and Stabilization
- Airway, breathing, circulation; large-bore IV access (two 18G or larger) or IO/central access if needed.
- Labs: CBC, BMP, LFTs, coagulation studies, type and crossmatch; pregnancy test when applicable; lactate.
- Resuscitation: balanced crystalloids; blood products using a restrictive strategy (transfuse when hemoglobin ≤ 7 g/dL; ≤ 8 g/dL if active cardiac ischemia or significant CAD).
- Platelets: target > 50,000/µL for active bleeding or planned procedures; > 100,000/µL for neurosurgical/ocular procedures.
- Anticoagulants/antiplatelets: reverse when appropriate (vitamin K, PCC; consider platelet transfusion for severe thrombocytopenia). Weigh thrombotic risk.
- Early PPI: high-dose IV PPI for suspected nonvariceal UGIB (before or at endoscopy).
- Suspected variceal bleed: start vasoactive therapy (e.g., octreotide or terlipressin) and prophylactic antibiotics (e.g., ceftriaxone) promptly; consult GI/hepatology.
Risk Stratification and Disposition
- Pre-endoscopy risk tools (e.g., Glasgow‑Blatchford Score) help identify low-risk UGIB suitable for early discharge vs those needing admission/urgent endoscopy.
- ICU care for ongoing hemodynamic instability, transfusion requirement, active comorbidities, or high-risk lesions.
Diagnostic Pathway
Upper GI Bleeding
- Upper endoscopy (EGD) within 24 hours for most; within 12 hours for suspected varices or ongoing instability.
- Nasogastric tube lavage may be selectively used; not routinely required.
Lower GI Bleeding
- If brisk ongoing bleeding: CT angiography (CTA) localizes active extravasation and guides embolization.
- After stabilization and bowel prep: colonoscopy for diagnosis and therapy.
Obscure/Small-Bowel Bleeding
- Capsule endoscopy when EGD/colonoscopy are negative and bleeding persists.
- Deep enteroscopy (balloon-assisted) for therapy if lesions found.
- Angiography with embolization for CTA-positive active bleeding.
Therapeutic Options
Endoscopic Hemostasis (UGIB)
- Peptic ulcers: use dual therapy (e.g., epinephrine injection plus thermal coagulation or mechanical clips). Avoid epinephrine alone.
- Visible vessel/active bleeding/oozing: treat endoscopically; then high-dose IV PPI infusion for 72 hours, followed by oral PPI.
- Mallory–Weiss tears: often self-limited; treat if active bleeding (clips/thermal/injection).
- Dieulafoy lesion: mechanical clipping/band ligation; sometimes over-the-scope clip.
Variceal Hemorrhage
- Resuscitate with caution to avoid over-transfusion (target Hgb ~7–8 g/dL).
- Vasoactive agents and antibiotics as above.
- Endoscopic variceal ligation (EVL) for esophageal varices; cyanoacrylate for gastric varices.
- Consider early TIPS for refractory or high-risk bleeding after initial control.
Lower GI Hemostasis
- Colonoscopic therapy: epinephrine injection, thermal coagulation, or clipping of culprit lesions (e.g., diverticular stigmata, angiodysplasia).
- If endoscopy fails or patient unstable: CTA-guided transcatheter arterial embolization.
- Surgery reserved for persistent/recurrent bleeding not controlled by endoscopy/IR or when malignancy requires resection.
Post-bleed Care and Secondary Prevention
- Test and eradicate H. pylori for peptic ulcer bleeding.
- Discontinue or minimize NSAIDs; if antiplatelets are required, coordinate resumption timing with cardiology; maintain PPI co-therapy when indicated.
- For varices: start nonselective beta‑blocker (e.g., carvedilol or propranolol) once stable; schedule surveillance EVL until eradication; manage portal hypertension and alcohol use disorder.
- Iron replacement for iron‑deficiency anemia; arrange follow-up endoscopy/colonoscopy based on findings.
Red Flags Requiring Immediate Action
- Hypotension/syncope, ongoing hematemesis or large-volume hematochezia
- Failure to respond to resuscitation or need for massive transfusion
- Signs of peritonitis, bowel ischemia, or perforation
Key Takeaways
- Rapid resuscitation and early risk stratification are critical.
- UGIB: EGD within 24 h (12 h for varices); use dual endoscopic therapy plus high-dose PPI.
- Variceal bleeding: vasoactives + antibiotics + EVL; consider early TIPS if refractory.
- Brisk LGIB: CTA first; colonoscopy for diagnosis/therapy once stable.
- Always address secondary prevention (H. pylori, NSAID/anticoagulant management, portal hypertension).