Gastrointestinal bleeding

Background

• Loss of blood from the GI tract distal to the ligament of Treitz
• Upper GI bleeds are most common source for blood detected in the lower GI system
• 80% of lower GI bleeding will resolve spontaneously
• Cause for bleeding is found in <50% of cases

Diagnosis

History

• Hematochezia
  • Bright red or maroon-colored bleeding that comes from the rectum
  • Usually represents lower GI bleeding
  • May represent UGIB if bleeding is brisk
    • Usually accompanied by hematemesis and hemodynamic instability
• Melena
  • Usually represents bleeding from upper GI source
  • May represent bleeding from lower GI source due to slow bleeding

DDX

1. Upper GI bleed
2. Diverticular disease
3. Colitis
   1. Infectious
   2. Ischemic (90% of cases occur in age >70yo)
4. Adenomatous polyps
5. Malignancy

1. Diverticulosis (painless, voluminous)
2. Infectious (virus, bacteria, parasites, C. dif)
3. Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
4. IBD (fistula-in-ano)
5. Angiodysplasia
6. Cancer/polyps
7. Rectal dz
8. Hemorrhoids
   1. External (below pectinate); Internal (above)
9. Ulcer (HIV, syphilis, STDs)
10. Fissures (painful defecation)
11. Abscess, prolapse, proctitis, impaction

Consider

1. Proctoscopy (22cm from anal verge)
2. Sigmoidoscopy (60cm from anal verge)
3. Angiography (requries arterial bledding >0.5cc/min)
4. CT angio

Disposition

Rockall score

Home (very low risk)

1. No comorbid dz
2. Normal vitals
3. Norma/trace pos guiac
4. Normal/near-normal Hb
5. Home support
6. F/U within 24hrs

Ward/Stable (low risk)

1. Age <60
2. Initial SBP >100
3. Normal vitals x 1hr
4. No transfusion req
5. No major comorbid
6. No liver dz

ICU

1. Normal or dec Hct
2. Blood in NG doesn't clear
3. SBP<100, HR>100
4. Gauaic +/- stool

False Positive Guaiac

1. Red fruits and meats
   1. (Bananas, turnips, broccoli)
2. Methylene blue
3. Chlorophyll
4. Iodide
5. Cupric sulfate
6. Bromide
7. Iron (causes GI bleed by irritation)

Source

• Tintinalli