GI 16: GI Bleeds

❤‍🔥 Gastrointestinal (GI) Bleeding — Overview

📊 Incidence

• 390,000 principal hospitalizations per year

• 600,000 cases as secondary diagnosis

• Mortality:

  • UGIB: 4.5–8.2%

  • LGIB: 3.0–8.8%

🧠 Remember: Upper bleeds are slightly more deadly due to risk of massive hematemesis and shock.

🧍‍♀ Clinical Presentation

🩺 History

Ask about:

• New medications or recent exposures (NSAIDs, anticoagulants, steroids, alcohol)

• Comorbidities: Liver disease, peptic ulcer disease, malignancy

• Symptoms: Frequency, amount, color, timing of blood loss

• Associated findings: Vomiting, melena, hematochezia, fatigue, syncope

🧠 Why this matters: History often points to location and cause of bleed (e.g., varices in cirrhosis vs ulcer from NSAIDs).

💓 Physical Examination

Look for:

• Vital signs: Hypotension + tachycardia → hypovolemia

• Skin: Cool, clammy (shock); petechiae or purpura (platelet/coagulopathy signs)

• Signs of liver disease:

  • Spider angiomas 🕷

  • Palmar erythema ❤

  • Jaundice 💛

• Abdomen: Distension, ascites, tenderness

• Rectal exam:

  • Detects blood or melena

  • Persistent bleeding when pressure applied → active rectal bleeding

🧠 Mini-why: petechiae = small capillary bleeds (1–2 mm red dots). they indicate platelet issues, not big vessel rupture.

🧪 Laboratory Testing

Order ASAP:

• Type and crossmatch → prep for transfusion

• CBC (hemoglobin, platelets)

• Electrolytes + glucose (hemodynamic stability)

• LFTs (check for liver dysfunction)

🧠 Why: baseline labs show severity and guide transfusion thresholds.

💉 Key Symptoms — Determine Bleeding Site

🧠 Mnemonic tip:
👉 “Melena = Midnight tar” (black, digested)
👉 “Hematochezia = Cherry red, colon-fed.”

⚖ Differentiating Upper vs Lower GI Bleeds

🧠 Quick clue:

• Upper = vomiting blood, black stool, liver disease link

• Lower = fresh blood, often older adults, vascular or inflammatory cause

🩸 Anatomical Definitions

🧠 Mini-why: The ligament of Treitz marks the transition between duodenum and jejunum — a key landmark for bleed classification.

💊 Drug-Related Causes of GI Bleeding

🧠 Mnemonic: “WAC N³S” = Warfarin, Antiplatelets, Corticosteroids, NSAIDs, SSRIs.

🔍 How to Suspect an Upper GI Bleed

💬 Historical Factors

⚡ Symptoms

🩸 Physical Signs

🧪 Labs

🧠 Why Urea:Cr↑ in UGIB?
Blood digested in stomach → absorbed as protein → ↑ urea formation.

📈 Risk Stratification

• Glasgow–Blatchford Score (GBS):

  • Score 0–1 → safe for outpatient management

  • Higher → admit + scope

🧠 Clinical pearl: Used to triage urgency — not to confirm the diagnosis.

🏥 Management of Upper GI Bleed

1⃣ Resuscitation

• IV crystalloids ± blood transfusions

• Monitor vitals + urine output

2⃣ Medications

• PPI: Protect clot + stabilize pH (see below)

• Octreotide: If variceal bleeding suspected

• Hold anticoagulants/antiplatelets if clinically necessary

3⃣ Endoscopy

• Diagnostic + therapeutic (done early)

💉 Blood Transfusions

• Hgb may initially appear normal (hemodilution hasn’t occurred yet!)

• Restrictive transfusion threshold:
  → Transfuse if Hgb < 70 g/L (some use < 80 g/L if cardiac disease)

• Expected effect:

  • 1 unit PRBC ↑ Hgb by ≈10 g/L

🧠 If Hgb doesn’t rise after transfusion → suspect ongoing bleed or hemolysis.

⚗ Proton Pump Inhibitors (PPIs)

⚠ Why PPIs Are Critical in UGIB

Acidic environment:

• ↓ platelet aggregation

• ↑ pepsin activation → digests blood clots

• ↑ fibrinolysis → clot breakdown

👉 therefore, PPI = stabilizes clot and prevents rebleeding

🕐 Timing & Use

🧠 Sequence to remember:
Suspect UGIB → give PPI → scope

💊 PPI Dosing Examples (recognize, not memorize)

🧠 Don’t confuse:
PPIs are superior to H₂RAs — they lower rebleeding, surgery, and mortality.

🩸 Variceal Bleeding

🧠 Definition:
Bleeding from dilated veins (varices) in the esophagus or stomach — usually due to portal hypertension from cirrhosis.
💀 High mortality if not managed fast.

💊 Pharmacologic Management

🧠 Why antibiotics?
Cirrhosis + GI bleed = ↑ gut permeability → bacteria move from gut → bloodstream (↑ risk of sepsis).
→ Prophylaxis cuts mortality risk nearly in half.

🩺 Procedural Management

🌈 Post-Bleed Management (after endoscopy)

After the gastroenterologist classifies the lesion:

🧠 Why: Keeps gastric pH high enough for mucosal healing + clot stabilization.

💩 Lower GI Bleeding (LGIB)

• Accounts for ~20% of all GI bleeds

• Presents as hematochezia — maroon or bright red blood from the rectum

• Usually less severe but still needs prompt assessment

💉 Common Causes

🧠 Mnemonic: “Divert, Die, Dilate, Disease” = Diverticulosis, Malignancy, Angiodysplasia, Colitis.

🔬 Colonoscopy in LGIB

🚽 Bowel Preparation — Key for Clear Visualization

Inadequate prep can:

• ↑ procedural risk

• ↑ duration of insertion + total procedure time

• ↓ adenoma detection

• ↓ cecal intubation rate

• Require repeat procedure sooner

🚫 Patient-Related Risk Factors for Poor Prep

🧠 How to fix it: Reinforce prep instructions early, choose patient-friendly regimens, and manage constipation beforehand.

✅ End of Variceal & Lower GI Bleed Section Summary

🌟 EOB-Style Key Takeaways

🚽 Bowel Preparation Pharmacology

💧 1⃣ Isosmotic Preparations (Polyethylene Glycol – PEG)

🧠 Why large volume? it flushes everything out evenly without drawing or pushing water across the bowel wall — so minimal systemic effect.

⚗ 2⃣ Hyperosmotic Preparations

🧠 Why riskier? hyperosmotic solutions shift fluid into the gut — great for cleansing, but can worsen dehydration or electrolyte swings.

⚡ 3⃣ Stimulant Preparations

🧠 Why combo works: magnesium oxide + citric acid = magnesium citrate in situ → adds osmotic pull + stimulant action.

🧴 4⃣ Magnesium Citrate (Citro-Mag)

🌟 Quick Comparison Table

✅ End of Bowel Prep Section

💡 EOB-Tips Recap

• PEG = safest for fragile pts (renal, elderly).

• Hyperosmotic/stimulant = faster but riskier.

• Always separate other oral meds by ≥ 2 h.

• Watch for electrolyte and magnesium changes.

• Encourage clear fluids to prevent dehydration.