Diagnosis

Gastrointestinal hemorrhage

Etiology

Cause of Upper GI --> Usually presents either as hematemesis or melena [q6d]

• Ulcer disease (gastrinoma, H. pylori infection, NSAIDs, or stress)

• Esophagitis

• Esophageal varices

• Portal hypertensive gastropathy

• Gastritis and Duodenitis

• Mallory-Weiss tear

• Dieulafoy lesion

• Angiodysplasia/arteriovenous malformation

• Upper GI tumors/cancer (esophagus/gastric)

• Gastric antral valvular ectasia (watermelon stomach)

• Cameron lesions (bleeding ulcers occurring at the site of a hiatal hernia)

• Aortoenteric fistulas

• Foreign body ingestion

• Post-surgical bleeds (anastomosis, polypectomy, sphincterotomy)

• Hemobilia

• Hemosuccus pancreaticus (bleeding from the pancreatic duct)

• Drug side effects (NSAIDs, SSRIs, corticosteroids, and anticoagulants)

Cause of Lower GI --> Most commonly presents as hematochezia [q6d]

• Diverticulosis/Diverticulitis

• Angiodysplasia/arteriovenous malformation

• Infectious colitis

• Acute mesenteric ischemia

• Ischemic colitis

• Aortoenteric fistula

• Ulcerative colitis

• Crohns disease

• Colon cancer/polyps

• Hemorrhoids

• Anal fissures

• Rectal varices

• Dieulafoy lesion

• Radiation

• Post-surgical (polypectomy, biopsy, anastomosis)

Risk factors [5pz]

• Older age

• Male

• Smoking

• Alcohol

• Medications

Complications [q6d]

• Respiratory Distress

• Myocardial Infarction

• Infection

• Shock

• Death

Epidemiology

Incidence per 100.000 [q6d][tur][5pz][89h][sir][ppz]

Approach

• Blood test: Hemoglobin, hematocrit, PT-INR, prothrombin time, APTT, Lactate, Liver function tests

• Blood gas

• Gastric lavage

• Rectal exam

• Hemofec

• Gastroscopy: Push enteroscopy

• Colonoscopy

• Nuclear scintigraphy: Tagged RBC scan

• CT angiography

Treatment

1. Resuscitation [q6d]

   • Nothing by mouth

   • Oxygen or intubation

   • IV fluid resuscitation

   • Blood grouping and cross match

   • Transfusions

     • RBC transfusion if hemoglobin < 7 g/dL

     • Platelet transfusion if the platelet count < 50,000/uL

     • Prothrombin complex concentrate if INR > 2

2. Investigating the underlying cause

3. Medications [q6d]

   • PPIs

   • Prokinetic agents

   • Vasoactive medications: Somatostatin or octreotide to treat variceal bleeding by inhibiting vasodilatory hormone release

   • Antibiotics: prophylaxis in patients with cirrhosis to prevent translocation

   • Anticoagulant/antiplatelet agents: Should be stopped if possible

     • Consider the reversal of agents on a case-by-case basis dependent on the severity of bleeding and risks of reversal

4. NGT lavage to remove fresh blood --> facilitate endoscopy

5. Blakemore or Minnesota tube if patients with hemodynamic instability/massive GI bleeds in the setting of known varices, which should be done only once the airway is secured. This procedure carries a significant complication risk (including arrhythmias, gastric or esophageal perforation).

6. Surgery in patients with massive bleeding or hemodynamic instability who have bleeding that is not amenable to any other treatment.

7. Diverticular bleeding --> colonoscopy with bipolar probe coagulation, epinephrine injection, or metallic clips

8. Angiodysplasia --> thermal therapy (electrocoagulation, argon plasma coagulation)

Differential diagnoses

Acute pancreatitis, Anal fissure, Aortic dissection, Aortoenteric fistula, Arteriovenous malformation, Cholecystitis, Colorectal cancer, Crohn disease, Dengue fever, Dieulafoys lesion, Diverticulitis, Drug side effects, Esophageal varices, Esophagitis, Gastritis, Hemobilia, Hemorrhoids, Infectious colitis, Ischemic colitis, Mallory-Weiss tear, Meckels diverticulum, Myocardial infarction, Proctitis, Radiation colitis, Radiation telangiectasia, Ruptured aortic aneurysm, Stroke, Ulcerative colitis, Ulcer disease, von Willebrand disease, Zollinger-Ellison syndrome