GI Haemorrhage

“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

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