Gastrointestinal (GI) bleeding management

Gastrointestinal (GI) bleeding management

Gastrointestinal (GI) bleeding refers to intraluminal blood loss occurring anywhere from the oropharynx to the anus.

Classification

• Upper GI bleeding (UGIB): Bleeding originating above the ligament of Treitz.

• Lower GI bleeding (LGIB): Bleeding originating below the ligament of Treitz.

Severe GI bleeding

Severe GI bleeding is defined by one or more of the following:

• Associated shock

• Orthostatic hypotension

• Fall in haematocrit by 6%

• Decrease in haemoglobin by 2 g/dL

• Requirement for transfusion of ≥2 units of packed red blood cells (PRBCs)

Patients with severe GI bleeding require hospitalization.

Upper GI bleeding (UGIB)

Peptic ulcer disease caused by Helicobacter pylori infection or NSAID use is the most common cause of non-variceal upper gastrointestinal bleeding.

Characteristic findings include:

• Haematemesis

• Melena

• Bright red blood per rectum (infrequently)

• Elevated serum BUN/creatinine ratio

Slow or chronic bleeding is suggested by iron deficiency and is typical of:

• Erosive disease

• Tumours

• Oesophageal ulcers

• Portal hypertensive gastropathy

• Cameron lesions (erosions found within large hiatal hernias)

• Angiodysplasia

Differential diagnosis of upper GI bleeding

Initial management

Assessment of severity

Assess:

• Vital signs

• Orthostatic changes

• Jugular venous pressure (JVP)

Clinical indicators of blood loss:

• Tachycardia (may be masked by β-blocker use) suggests approximately 10% volume loss.

• Orthostatic hypotension suggests approximately 20% volume loss.

• Shock suggests greater than 30% volume loss.

Endoscopic evaluation

• After stabilization, perform upper gastrointestinal endoscopy to identify the source of bleeding.

• If endoscopy demonstrates an ulcer, test for H. pylori infection.

Resuscitation

• Insert two large-bore intravenous cannulas (18-gauge or larger).

• Begin volume replacement with:

  • Normal saline (NS), or

  • Lactated Ringer's solution (LR)

• Aim to restore:

  • Normal vital signs

  • Adequate urine output

  • Normal mental status

Pharmacological treatment

Variceal bleeding

• Refer to Section 10.4.2.3: Bleeding Oesophageal Varices.

Bleeding peptic ulcer disease

• Pantoprazole (IV) 40 mg every 12 hours for 2–3 days

OR

• Esomeprazole (IV) 40 mg every 12 hours for 2–3 days

Laboratory investigations

• Full blood picture (FBP)

• Liver function tests (LFTs)

• Renal function tests (RFTs)

• Abdominal ultrasound

• Viral hepatitis screening

• H. pylori stool antigen test