IM : approach to git bleeding

What is the definition of hematemesis in GI bleeding?

vomiting of blood.

What is the definition of melena in GI bleeding?

passage of black ,offensive stool .

What is the definition of hematochezia in GI bleeding?

passage of fresh blood per rectum,

How much blood loss is required for hematemesis to manifest?

Up to 1000 ml

How much blood loss is required for melena to manifest?

little as 50-100 ml

What is the usual source of hematochezia, and when can it indicate upper GI bleeding?

from LGIB , 10% severe UGIB

What GI tract sources can cause melena?

bleeding anywhere in the GItT

What are the main causes of upper GI bleeding?

PHTN,PUD, Mallory-Weiss tear, vascular anomalies

What are the main causes of lower GI bleeding?

Diverticular disease, colitis , anorectal disease , and post-polypectomy bleeding.

What is the most common cause of upper GI bleeding related to portal hypertension?

Esophageal and gastric varices due to liver cirrhosis.

What percentage of cirrhotic patients develop varices?

one third

What is the risk of bleeding in cirrhotic patients with varices?

One-third

What is the 4-year mortality in patients with bleeding varices?

80% within 4 yrs.

Explain the pathophysiology of bleeding in portal hypertension.

Increased portal pressure → formation of portosystemic collaterals → high pressure in collateral vessels → rupture → bleeding.

What are prehepatic causes of portal hypertension leading to GI bleeding?

Portal vein thrombosis, splenic vein thrombosis, congenital atresia or stenosis of the portal vein, extrinsic compression by tumors.

What are posthepatic causes of portal hypertension leading to GI bleeding?

IVC thrombosis, right-sided heart failure, constrictive pericarditis, severe tricuspid regurgitation, Budd-Chiari syndrome.

What percentage of upper GI bleeds are due to peptic ulcer disease?

Around 50% of cases in Western countries.

What is the mortality associated with peptic ulcer disease-related GI bleeding?

Approximately 6%.

Why has peptic ulcer disease bleeding declined recently?

Due to eradication of H. pylori and prophylaxis in high-risk NSAID users with proton pump inhibitors.

What is a Mallory-Weiss tear in GI bleeding?

Laceration of mucosa at gastroesophageal junction, often after retching or vomiting.

What percentage of upper GI bleeds are due to Mallory-Weiss tears?

About 5-10%.

Who are typical patients with Mallory-Weiss tear?

Alcoholics or those with severe retching/vomiting.

Is Mallory-Weiss bleeding severe or recurrent?

Usually not severe or recurrent.

What is the best diagnostic test for Mallory-Weiss tear?

Upper GI endoscopy.

What proportion of upper GI bleeding is due to vascular anomalies?

Around 7%.

What are vascular ectasias (angiodysplasias)?

Bright red stellate-shaped vascular lesions in the GI mucosa.

With what systemic diseases are vascular anomalies associated?

Hereditary hemorrhagic telangiectasia, CREST syndrome, chronic kidney disease, ischemic heart disease.

What is a Dieulafoy lesion in GI bleeding?

An aberrant large submucosal artery (often proximal stomach) that causes recurrent intermittent bleeding.

What is Gastric Antral Vascular Ectasia (GAVE)?

Dilated small blood vessels in the gastric antrum causing chronic GI bleeding or iron deficiency anemia ("watermelon stomach").

What conditions are associated with GAVE?

Portal hypertension, chronic kidney failure, collagen vascular disease, scleroderma (especially systemic sclerosis).

What is the histological hallmark of GAVE?

Dilated capillaries in lamina propria with fibrin thrombi.

What percentage of GAVE patients have cirrhosis?

Around 30%.

What percentage of upper GI bleeding is due to gastric neoplasms?

About 1%.

What type of bleeding is seen with erosive gastritis?

Usually mild acute bleeding or chronic occult bleeding leading to anemia.

What are common causes of erosive gastritis?

NSAIDs, alcoholism, severe illness (stress ulcers, stress-related mucosal disease).

What are causes of erosive esophagitis leading to bleeding?

Severe GERD, esophageal neoplasms.

Name rare but important other causes of upper GI bleeding.

Aortoenteric fistula, hemobilia, pancreatic malignancy, hemosuccus pancreaticus (bleeding from pancreatic pseudoaneurysm).

What is aortoenteric fistula and when does it occur?

Abnormal communication between aorta and intestine, often after abdominal aortic surgery.

What is hemobilia as a cause of GI bleeding?

Bleeding into biliary tract due to hepatic tumor, angioma, or trauma.

What is hemosuccus pancreaticus?

GI bleeding from rupture of a pancreatic pseudoaneurysm into the pancreatic duct.

What are the common anorectal causes of lower GI bleeding?

Hemorrhoids, anal fissures, rectal carcinoma.

What is post-polypectomy bleeding in lower GI bleeding?

Bleeding complication after removal of colonic polyps, either immediate or delayedWhat are the stigmata of liver cirrhosis on physical exam in GI bleeding?; Jaundice, palmar erythema, muscle wasting, ascites, spider navi, caput medusae

What does cachexia on physical exam in GI bleeding indicate?

Chronic disease and poor nutritional status, often linked with chronic liver disease

What do signs of chronic liver disease on exam in GI bleeding imply?

Implicate portal hypertension and varices, though another cause can be found in 25% of patients

What is the first step in ER management of significant GI bleeding?

Maintain IV access with 2 large-bore (18G or larger) IV cannulas before diagnostics

What blood investigations are urgently required in ER management of GI bleeding?

Blood grouping, screening, routine labs, and preparation for transfusion based on hemodynamic status

What factors guide blood replacement needs in GI bleeding?

Hemodynamic parameters, active bleeding, and lab findings

What is the fluid replacement strategy in less severe GI bleeding without hemodynamic compromise?

IV fluids (e.g., lactated Ringer's, 10% dextrose) guided by hemodynamic stability, avoiding over-infusion

What blood product is given to maintain Hb in GI bleeding and at what level?

Packed RBCs, to maintain Hb 6-10 g/dL depending on hemodynamics and comorbidities

When should blood transfusion be given in GI bleeding?

In active bleeding regardless of hemoglobin level

When is platelet transfusion indicated in GI bleeding?

Platelets <50,000 or history of aspirin/clopidogrel use

When should fresh frozen plasma be given in GI bleeding?

If coagulopathy present; INR should be <2.5 before endoscopy

What is the FFP to blood transfusion ratio in severe GI bleeding?

One unit FFP per 5 units blood

What is the best diagnostic test for upper GI bleeding?

Upper GI endoscopy

What are the roles of endoscopy in upper GI bleeding?

Establish diagnosis, treat cause (sclerotherapy, banding, clipping, laser, epinephrine, cautery), and determine risk of rebleeding

What mechanical method can stop bleeding in GI bleeding emergencies?

Sengstaken tube for mechanical compression

What is the mechanism of vasopressin in pharmacologic management of GI bleeding?

Causes severe vasoconstriction in the splanchnic bed, reducing blood flow and aiding hemostasis

What is the mechanism of octreotide (somatostatin analogue) in GI bleeding?

Continuous IV reduces splanchnic and portal blood flow; terlipressin is an alternative

In which patients is vasopressin contraindicated in GI bleeding?

Severe coronary artery disease and peripheral artery disease

What are limitations of vasopressin/octreotide therapy in GI bleeding?

Less effective in severe atherosclerosis and coagulopathy

What is the role of IV PPIs in GI bleeding?

Used in bleeding peptic ulcers with and after endoscopic therapy

What interventional radiology option exists in refractory GI bleeding?

Intra-arterial embolization during angiography

What surgical/radiological option reduces portal pressure in variceal bleeding?

TIPS (transjugular intrahepatic portosystemic shunt)

What is endoscopic band ligation used for in GI bleeding?

Treatment of esophageal varices

What is sclerotherapy injection used for in GI bleeding?

Treatment of gastric varices

What is the first-line management for Mallory-Weiss tear bleeding?

Esophageal clips at the site of active bleeding

What endoscopic method besides clips can manage Mallory-Weiss tear?

Endoscopic band ligation (effective and safe)

What radiological method can treat Mallory-Weiss tear bleeding?

Angiographic embolization of feeding vessels

What injection therapy can be used in Mallory-Weiss tear?

Epinephrine injection

What is the endoscopic treatment for Gastric Antral Vascular Ectasia (GAVE)?

Argon plasma coagulation and electrocautery

What medical treatments have been tried for GAVE?

Estrogen and progesterone therapy

With what conditions is GAVE commonly associated?

Portal hypertension, chronic kidney failure, collagen vascular diseases (esp. scleroderma/systemic sclerosis)

What is the goal of therapy for bleeding esophageal varices?

Stop bleeding and prevent rebleeding using band ligation, sclerotherapy, pharmacologic therapy, or TIPS

What is the role of acid suppression in GI bleeding?

IV PPIs reduce risk of rebleeding in peptic ulcer bleeding

How is severity of lower GI bleeding assessed?

Based on hemodynamic stability, ongoing bleeding, and transfusion requirements

What are endoscopic therapeutic options for upper GI bleeding?

Band ligation, sclerotherapy, clipping, laser photocoagulation, epinephrine injection, cauteryWhat does abdominal pain with diarrhea and hematochezia suggest?; Colitis (inflammatory or ischemic), not angiodysplasia (which usually doesn't cause pain).

What symptoms suggest colorectal cancer or inflammatory colitis?

Change of bowel habit, tenesmus, or weight loss.

What medication/travel history is important in lower GI bleeding?

Aspirin/NSAID use, recent antibiotics, recent travel.

Which conditions are common causes of LGIB in age >65?

Diverticular disease and angiodysplasia.

What type of rectal bleeding is usually seen with hemorrhoids?

Intermittent or chronic rectal bleeding.

What should acute bleeding in older patients prompt evaluation for?

Diverticular disease.

What does mild fever in a patient with LGIB suggest?

Infectious colitis or inflammatory bowel disease.

What physical findings may suggest colorectal cancer in LGIB?

Hepatomegaly or abdominal masses.

Why is rectal examination essential in LGIB?

To exclude a palpable rectal mass.

What labs are important in LGIB evaluation?

FBC (Hct, WBC, platelets), PT, aPTT.

What additional labs are required in acute/severe LGIB?

Blood group and cross-matching.

What lab marker may be elevated in IBD-related LGIB?

ESR.

What stool studies are useful in LGIB with diarrhea?

Stool WBC, culture, ova and parasite exam.

What is the role of NG tube in suspected LGIB?

Lavage to exclude upper GI bleeding (11% of LGIB cases are actually UGI sources).

What endoscopic tools are used in LGIB evaluation?

Anoscope, colonoscopy, OGD (if UGI source suspected).

What is radionuclide (RBC-tagged) scanning used for in LGIB?

Detects minimal bleeding (0.1 mL/min), non-invasive but no therapy possible.

What is CT abdomen useful for in LGIB?

Diagnosis of ischemic colitis or aorto-enteric fistula.

What is CT mesenteric angiography's role in LGIB?

Localizes active bleeding (sensitivity 89%, specificity 85%), allows therapeutic intervention.

What are risks of mesenteric angiography?

Renal failure, arterial thrombosis, contrast reactions.

What are the three components of LGIB management?

Resuscitation & assessment, localization of bleeding site, therapeutic intervention.

What endoscopic therapies are used for diverticular bleeding?

Bipolar coagulation, epinephrine injection, metallic clips, or segmental resection.

What endoscopic therapy is used for angiodysplasia bleeding?

Thermal therapy (electrocoagulation, argon plasma coagulation).

What endoscopic therapies are used for radiation-induced bleeding?

Formalin, Nd:YAG laser, argon plasma coagulation.

How is bleeding from polyps treated?

Polypectomy.

What is the management of neoplastic bleeding (colonic tumors)?

Surgical resection.