Upper & Lower GI Bleeding
(Gastrointest Endosc 2005;62:656-60 & 2004;60:497-504. Ann Intern Med 2003; 843-857.)
DEFINITION:
Intraluminal blood loss anywhere from the oropharynx to the anus (i.e. mouth to butt)
Classification: Upper » above the ligament of Treitz; Small Bowel » between lig of Treitz and IC valve; Lower » Colonic
Signs: Hematemesis: blood in vomitus (UGIB); Can be bright red or coffee grounds (darkened due to acid exposure)
Hematochezia: bloody reddish/maroon stools (usually LGIB, however 10-20% can be rapid UGIB or Small bowel bleed)
Melena: black, tarry, stinky stools from digested blood (usually UGIB but can be anywhere above and including the right colon)
Occult and Obscure, See also GI Bleed- Occult & Obscure Bleeding (Chapter 6.03)
EPIDEMIOLOGY:
UGIB ETIOLOGIES: (Am J Gastro 1998;93:1202-08)
Always consider oropharyngeal bleeding or epistaxis leading to swallowed blood
PUD (40-50%): Both Duodenal and Gastric!
Duodenal Ulcers (30%)
Gastritis/Gastrophathy: Gastric Erosions (27%) and Gastric Ulcers (22%) NSAIDs, H. Pylori, Stress-related mucosal disease
Erosive esophagitis (11%)
Duodenitis (10%)
Varices (5-30%); See also GI Bleed- Variceal Bleeding (Chapter 6.05)
Mallory-Weiss tear (5-15%) GE junction tear due to retching against closed glottis
Vascular Malformations (5%)
Dieulafoy’s lesion (superficial submucosal artery, majority within 6 cm of GEJ (but can occur anywhere) » sudden, massive GIB)
AVMs (may be isolated or occur with Osler-Weber-Rendu syndrome)
Gastric antral vascular ectasia (GAVE), aka: Watermelon stomach; primarily involves antrum and crosses the pylorus
Portal hypertensive gastropathy (PHG); primarily involves proximal stomach (fundus)
Aorto-enteric Fistula (Abdominal aortic aneurysm or aortic graft erodes to 3rd portion of duodenum; presents with ‘herald bleed’: small, then massive bleed)
Hemobilia (liver or biliary trauma, including liver biopsy); EGD shows blood coming from ampulla
Hemosuccus Pancreaticus (bleeding from peripancreatic vessels into PD); Angiography is diagnostic/therapeutic; Rarely surgery
Neoplastic disease (esophageal or gastric)
Other: Hiatal hernia ulcer (Cameron lesions), Vasculitis, Mixed connective tissue disease, Coagulopathy, Amyloid
LGIB ETIOLOGIES: (Am J Gastroenterol 1993;93:1202-08)
Hemorrhoids, Internal (most common cause in adults, 50-80% of population): intermittent, sometimes massive, often with defecation
Angiodysplasia 41% (age acquired, esp >50 years old; Most are in cecum and proximal ascending but can occur anywhere in GI tract)
Histologically: ecstatic, distorted thin-walled veins, venules, and capillaries in mucosa or submucosa
Most are subacute and recurrent bleeds, although 15% present with acute massive bleed, while 10% present with occult blood loss
Bleeding ceases spontaneously in >90% of cases
Diverticular 23% Right-side bleed more (occurs 3-5% of those with Diverticulosis; Bleeding reoccurs 25%, second recurrence is 50%)
Acute, massive, painless hematochezia; Stops spontaneously or with medical therapy in 75-95% of patients
Not a chronic process causing chronic occult blood loss; Surgical resection may be necessary; See also GI Bleed- Diverticular Bleeding (Chapter 6.02)
Neoplastic disease 15% (most are occult blood loss and Iron deficient anemia rather than acute blood loss
Most have variable bowel habits, weight loss; Physical exam can show palpable mass or rectal mass
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