Gastrointestinal bleeding can fall into two broad categories: upper and lower sources of bleeding. The anatomic landmark that separates upper and lower bleeds is the ligament of Treitz, also known as the suspensory ligament of the duodenum. This peritoneal structure suspends the duodenojejunal flexure from the retroperitoneum. Bleeding that originates above the ligament of Treitz usually presents either as hematemesis or melena whereas bleeding that originates below most commonly presents as hematochezia. Hematemesis is the regurgitation of blood or blood mixed with stomach contents. Melena is dark, black, and tarry feces that typically has a strong characteristic odor caused by the digestive enzyme activity and intestinal bacteria on hemoglobin. Hematochezia is the passing of bright red blood via the rectum.
Upper GI Bleeding
Lower GI Bleeding
Acute management of GI bleeding typically involves an assessment of the appropriate setting for treatment followed by resuscitation and supportive therapy while investigating the underlying cause and attempting to correct it.
Specific risk calculators attempt to help identify patients who would benefit from ICU level of care; most stratify based on mortality risk. The AIMS65 score and the Rockall Score calculate the mortality rate of upper GI bleeds. There are two separate Rockall scores; One is calculated before endoscopy and identifies pre-endoscopy mortality, whereas the second score is calculated post-endoscopy and calculates overall mortality and re-bleeding risks. The Oakland Score is a risk calculator that attempts to help calculate the probability of a safe discharge in lower GI bleeds.
Few diagnoses mimic GI bleeding. Occasionally, hemoptysis may be confused for hematemesis or vice versa. Ingestion of bismuth-containing products or iron supplements may cause stools to appear melanic. Certain foods/dyes may turn emesis or stool red, purple, or maroon (such as beets).
Limited studies exist regarding the prognosis following GI bleeding.
For upper GI bleeds, in-hospital mortality rates are approximately 10% based on observational studies. This rate holds steady up to 1-month post-hospitalization for GI bleed. Long-term follow-up of patients with UGIB shows that at three years after admission mortality rates from all causes approach 37%.
Mortality rates were higher in women than in men when adjusted for age, which differs from that of lower GI bleeding. Patients with multiple hospitalizations for GI bleeding carry higher mortality rates. Long-term prognosis was worst in patients who suffered from malignancies and variceal bleeds. The prognosis was worse with advancing age.
For lower GI bleeds, all-cause in-hospital mortality is low—less than 4%. Death from LGIB itself is rare, with most in-hospital mortality occurring from other comorbid conditions. Increased risk of death corresponded to increasing age (as seen in cases of UGIB as well), comorbid conditions, and intestinal ischemia. Other negative prognostic factors include secondary bleeding (onset of bleed after being hospitalized for a different condition), patients with pre-existing coagulopathies, hypovolemia, transfusion requirement, and male sex. Not surprisingly, the lowest risks of mortality are associated with more benign causes of LGIB such as hemorrhoids, anal fissures, and colon polyps. Long-term follow-up studies in patients with LGIB are not common.
A GI bleed is any bleeding occurring from the gastrointestinal system. This includes the esophagus, stomach, small intestine, and large intestine (also known as the colon). Bleeding from the GI system can come from the upper GI tract (esophagus, stomach, and part of the small intestine) or the lower GI tract (second part of the small intestine and the large intestine). Some symptoms of GI bleeding are obvious, such as vomiting bright red blood or blood that looks like coffee-grounds or seeing bright red blood in the toilet with bowel movements. Some symptoms of GI bleeding are more subtle, such as dark or tar-like stools, belly pain, diarrhea, anemia (which is a low red blood cell count), weakness, lightheadedness, shortness of breath, pale skin, or a racing heart. There are many causes of bleeding from the GI tract. The doctor may perform a series of tests to evaluate concerns of a gastrointestinal bleed. Some of these tests check the blood for cell counts and clotting ability. Some tests include imaging to try to see from where the blood is coming.
Some tests are relatively invasive compared to others but allow for direct observation of the GI tract, such as an esophagogastroduodenoscopy (EGD) or a colonoscopy. In these procedures, the doctor gives medication to relax the patient and inserts a flexible scope with a light and camera from the mouth or the anus to observe the parts of the GI system it concerns them is bleeding. If there is bleeding, treatment may commence with oxygen, fluids through an IV, blood transfusions, or various medications to help stop the bleeding, reduce acid production, or empty the stomach. Patients can help avoid some causes of GI bleeding by not taking certain medications including NSAIDs (such as ibuprofen or naproxen) and receiving treatment for stomach ulcers or liver disease.
Care of patients with gastrointestinal bleeding requires coordinated and efficient interprofessional cooperation. Nurses manage the frequent monitoring of vital signs and more short-term interaction with and observation of patients. They must communicate their findings with the physicians, who use their own and nursing observations to make decisions for treatment. Multiple physicians may be necessary for treatment. General internists are typically responsible for the routine care of patients with GI bleeds. Critical care physicians may be involved if the patient warrants ICU level care for severe hemorrhages. Gastroenterologists perform endoscopic examinations and treatment if able during those procedures. Radiologists will interpret various imaging modalities and conveying those results to the providers. Interventional radiologists may perform diagnostic procedures, with the ability to also perform therapeutic modalities such as angiography-guided embolization. In some severe cases, general surgeons may be involved for intervention or exploratory procedures. Pharmacists are essential for providing oversight of medications used in the setting of bleeds and ensuring the use of proper dosages. A coordinated effort by all of these healthcare professionals is necessary for early recognition and intervention in gastrointestinal bleeds to prevent further morbidity or mortalities.
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