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Gastrointestinal bleeding can range from occult (no symptoms, only found on occult blood test) to severe and life-threatening. It may manifest as haematemesis, haemodynamic instability, melena, or haematochezia.
Acute GI bleeding requires hospitalisation and urgent assessment and treatment. Mortality is high, 5 – 20%. Upper GI bleeding is 5x more frequent than lower GI bleeding.
- Peptic ulcer
- Oesophageal varices (due to portal hypertension due to cirrhosis)
- Mallory-Weiss syndrome
- Erosive gastritis
1/3 of patients with cirrhosis develop variceal bleeding in the first 2 years. Mortality rate is very high, up to 40%.
- Peptic ulcer
- Oesophageal varices
- Diverticulosis (most common cause overall)
- Inflammatory bowel disease
- Infectious colitis (inflammatory diarrhoea)
- Colorectal cancer
Haematemesis refers to vomiting of fresh blood, clotted blood, or coffee grounds-like material. Haematochezia refers to fresh or clotted blood per rectum and is typically a sign of lower GI tract bleeding, while melena refers to passage of black tarry stool and is typically a sign of upper GI tract bleeding. However, large (> 1L) upper GI bleeding may cause haematochezia as well.
Haematemesis mostly occurs in large bleedings.
Diagnosis and evaluation
Colonoscopy is the investigation of choice for haematochezia, unless the bleeding is acute, massive and/or the patient is hypovolaemic. In that case, upper endoscopy should be prioritised, as an upper GI bleeding source is more likely. Both colonoscopy and upper endoscopy allow for both diagnosis and, in some cases, treatment of the bleeding.
Obtaining the patient’s bleeding parameters, medication list, and previous history are important to determine the source. As examples, anticoagulants can be reversed, known cirrhosis increases the likelihood of the source being oesophageal varices, and so on.
Aspiration of gastric contents through a nasogastric tube allows for quick differentiation between upper and lower GI bleeding. The aspirate is bloody in case of upper bleeding and clear in case of lower.
The Blatchford scoring system may be used to assess the risk of upper GI bleeding based on vital parameters, comorbidities, lab tests, and clinical features.
In case of acute bleeding, urgent assessment and stabilisation are crucial. If the patient is haemodynamically unstable, they must be stabilised first. This involves monitoring, replacing lost fluids, and blood transfusion. Blood transfusion is usually indicated at haemoglobin level < 70 g/L, with a target of 70 – 90 g/L.
Then, we should determine the source of the bleeding, stop it, treat the underlying condition, and prevent recurrent bleeding.
Non-variceal upper GI bleeding stops spontaneously in most cases, but rebleeding in the next days is common. These bleedings are usually due to ulcers, and treatment involves endoscopy and IV PPI. Haemostasis may be achieved endoscopically with electrocoagulation, heat, laser, clipping, banding, adrenalin injection, etc.
Variceal upper GI bleeding is severe and rarely stops spontaneously. There are many options for treating variceal bleeding, including:
- Balloon tamponade
- Vasopressin or somatostatin analogues
- Endoscopic therapy (sclerotherapy, ligation)
Surgical therapy is indicated if endoscopic therapy fails, if the ulcer is large (> 2 cm), if there is perforation, or if the bleeding is so large that the patient requires many units of blood (4 – 6). However, > 90% of gastrointestinal bleedings are managed without surgery. For surgical therapy, see topic B16 of surgery-traumatology.
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