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INTRODUCTION

Gastrointestinal (GI) bleeding is categorized into upper GI bleed (UGIB), bleeding from a source proximal to the ligament of Treitz, and lower GI bleed (LGIB) occurring distal to this duodenojejunal junction point.

TYPICAL CLINICAL PRESENTATIONS

  • Upper GI bleed: hematemesis (bright red blood or coffee ground) and/or melena

  • Lower GI bleed: hematochezia (bright red blood per rectum)

ETIOLOGY

  • Likelihood of various etiologies depends on age and geography.

  • Upper GI causes include coagulopathy, gastric or duodenal ulcer, gastritis, Mallory-Weiss tear, varices, esophagitis, and foreign body.

  • Lower GI causes include anal fissure, milk protein colitis, coagulopathy, vascular malformations, necrotizing enterocolitis, malrotation with midgut volvulus, intussusception, infectious colitis, Meckel's diverticulum, inflammatory bowel disease, hemolytic uremic syndrome (HUS), Henoch-Schonlein purpura (HSP), lymphonodular hyperplasia, and graft-versus-host disease.

DIAGNOSTIC EVALUATION

  • Physical exam: Look for evidence of shock in vital signs, pulses, and perfusion. Evaluate for abdominal distension or tenderness, ascites, jaundice. Examine the anus for fissures.

  • History: Ask about Timing/frequency, abdominal pain, severity/amount of blood loss, comorbid conditions, medication exposure, and associated symptoms.

  • Serum labs: Coagulation factors, complete metabolic panel, amylase, lipase, complete blood count

  • Stool guaiac in lower GI bleed

  • Stool for testing for infectious etiology if indicated by the history and symptoms

MANAGEMENT

  • Initial evaluation should focus on assessment and treatment of shock in cases of severe and/or brisk bleeding.

  • If patient is hemodynamically unstable, follow resuscitation pathway for hemorrhagic shock.

    • Establish IV access, preferably two large-bore IVs.

    • Initial labs should include type and cross-match of blood. If patient has significant hemodynamic instability, obtain universal donor blood products quickly.

    • Resuscitation of hemodynamics should focus on giving blood products. Guidelines for traumatic hemorrhagic shock resuscitation recommend high ratio of plasma:packed red blood cells. Ratio of 1:1 or 1:2 (plasma:PRBC) is appropriate.

  • Gastric lavage via nasogastric tube to evaluate for presence of ongoing gastric bleeding is an option, though negative lavage does not entirely rule out bleeding.

  • Initiate proton pump inhibitor, which may help to reduce UGIB.

  • Consider prophylactic antibiotics in patients with UGIB from esophageal varices.

  • In ongoing UGIB, octreotide or somatostatin may be helpful to diminish bleeding, especially in variceal bleeding.

  • Endoscopy/colonoscopy is often indicated for diagnosis and/or therapy to stop bleeding.

  • Endoscopy is ideally performed once patient has been resuscitated and bleeding is better controlled. In cases of ongoing severe bleeding, endoscopy may be indicated for acute therapeutic interventions.

  • If source of bleeding is not identified via endoscopy, other diagnostic modality options include angiography, tagged red cell scan, or video capsule endoscopy.

SUGGESTED READINGS

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Chang R, Holcomb JB. Optimal fluid therapy for traumatic hemorrhagic shock. Crit Care Clin. 2017;33:15–36.  [PubMed: 27894494]
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Richard L. Management of upper gastrointestinal bleeding in children: Variceal and nonvariceal. Gastrointest Endosc Clin N Am. 2016;26:63–73.  [PubMed: 26616897]
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Sahn B, ...

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