Gastrointestinal System >
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
- 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
- Suspected upper GIH:
Complications
- Hypovolemic shock
- Anaemia
- Iatrogenic complications such as aspiration pneumonia & perforation