“Bleeding in the GI tract (upper GIH: above ligament of Treitz & lower GIH: below ligament of Treitz) that may be visible or occult, i.e. no visible evidence”

Risk Factors
  • Modifiable:
    • Medications (NSAIDs, SSRIs, Anti-coagulation therapy)
  • Non-Modifiable:
    • Previous GI Haemorrhage
    • Age
    • Severe co-morbidities
Aetiology
  • Upper GI Haemorrhage:
    • Peptic ulcer disease
    • Erosive oesophagitis
    • Oesophageal varices
    • Mallory-Weiss syndrome & cancers of upper GI tract
    • AV malformations
  • Lower GI Haemorrhage:
    • Diverticulosis
    • Haemorrhoids
    • Intestinal ischemia
    • Colorectal cancer
    • AV malformations
Pathophysiology
  • Inflammatory
  • Vascular
  • Infectious
Clinical Presentation
  • Abdominal pain, lethargy, fatigue, syncope, angina, SOB, low BP, diaphoresis
  • Upper GIH:
    • Coffee-ground emesis and/or melena (black stools)
  • Lower GIH:
    • Haematochezia (bright red)
    • Right colon bleed (mix well with stools)
    • Left colon bleed (doesn’t mix well with stool)
Investigations
  • Assess haemodynamic instability: mild < 15% BV loss, > 40% BV loss then severe
  • FBC: electrolytes, BUN, Creatinine (assess renal function and dehydration), LFT (assess liver function), coagulation test, (rule out bleeding disorders
Management
  • If haemodynamically unstable:
    • IV-fluid resuscitation (at least 30 min, followed by reassessment)
    • IV PPIs (bolus dose, followed by maintenance dose 2x daily)
    • Blood transfusion is still unstable.
  • If haemodynamically stable:
    • Suspected upper GIH:
      • Upper endoscopy (within 24 hrs) with appropriate endoscopic therapy (e.g. thermocoagulation
      • Haemostatic clips
      • Variceal ligation or adrenaline injection)
      • Anti-emetic agents
      • Surgical repair or oesophageal resection (rare)
    • Suspected lower GIH:
      • Colonoscopy (within 24 hrs with adequate bowel preparation) with appropriate endoscopic therapy or CT angiography with vasoconstriction (vasopressin)
      • Surgical resection
      • Chemotherapy (for colorectal cancer)
      • Pain relief
Complications
  • Hypovolemic shock
  • Anaemia
  • Iatrogenic complications such as aspiration pneumonia & perforation

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