- Written By: Sarah Farris, MD, Duke University, Durham, North Carolina
- Edited By: David Gordon, MD, Duke University, Durham, North Carolina
- Last Updated: 2008
Gastrointestinal bleeding is a potentially life-threatening condition that is frequently seen in the emergency department. Gastrointestinal bleeding (GIB) is described by the anatomical area that is bleeding and most commonly simplified into “upper GI bleeding” and “lower GI bleeding.” The Ligament of Treitz which extends from the small intestine at the duodenojeunal junction serves as the anatomic landmark. Bleeding proximal to the ligament is classified as upper GI bleeding (UGIB); bleeding distal to the ligament is classified as lower GI bleeding (LGIB). UGIBs make up approximately 70% of all GI bleeds.
Upon completion of this self-study module, you should be able to:
- Discuss the initial assessment and management of a patient presenting to the emergency department with GIB
- Explain how to differentiate between upper and lower GIB
- List the different causes of upper and lower GIB
- Discuss basic criteria for transfusing patients with GIB
- Explain how and when to correct clotting disorders in patients with GIB
- Discuss the treatment for different causes of GIB
- Discuss the disposition of patients with GIB
What initial actions should be taken in patients presenting with gastrointestinal bleeding?
- Perform the primary survey
- Assess the location and rate of bleeding
- Determine the need for blood transfusion
- Determine the need for correction of a clotting disorder
Airway, breathing, and circulation must be readily assessed in patients with GIB. Intubation may be necessary for airway protection in patients with severe hematemesis or in patients with a depressed level of consciousness secondary to hemorrhagic shock. Patients with GIB should receive supplemental oxygen and placed on a cardiac monitor. Immediate IV access should be obtained with two large bore IVs (16 or 18 gauge) at a minimum. In the presence of tachycardia, hypotension or active bleeding, fluid boluses of isotonic crystalloid should be administered. Consider early transfusion of O negative or type-specific packed red blood cells without waiting for cross-matched blood if vital signs remain abnormal after 2 L of fluid.
Location and rate of bleeding
Nasogastric aspiration is a traditional component of the evaluation of GIB to help localize the source (upper versus lower) and assess the rate of bleeding. Hematemesis is indicative of an upper source of GIB, so the role of nasogastric aspiration in this setting is to determine whether the bleeding is active and severe. Melena and hematochezia can occur due to bleeding anywhere along the gastrointestinal tract, so nasogastric aspiration may help confirm an upper source. In both situations, the results of nasogastric aspiration may help guide treatment (e.g., urgency of an upper endoscopy) and disposition of the patient. Nasogastric aspiration, however, is associated with pain and has limited accuracy, so its use on a routine basis is a debated topic. This is further discussed in the Massive GI Bleed self-study module.
Aside from persistent hypotension despite appropriate fluid resuscitation (i.e., hemorrhagic shock), there are no hard and fast rules for when to transfuse packed red blood cells in patients with GIB. The decision is largely made on an individualized basis. A hemoglobin level of 6-7 g/L may be well tolerated by a young healthy adult but in an elderly patient precipitate myocardial ischemia. Factors involved in the decision to transfuse include the rate of active bleeding, absolute hemoglobin level, rate of hemoglobin drop, and end-organ injury. Conditions in which transfusion should be performed or strongly considered include:
- Massive upper or lower GI bleed (e.g., passing 1000 mL maroon-colored thin liquid stools every 20-30 minutes or NGT putting out a steady stream of bright red blood with continuous suction)
- Hemoglobin dropping >3 g/dL over 2-4 hours in the setting of active bleeding
- Hemoglobin below 9 g/dL in the setting of active bleeding
- Anemia induced end-organ injury (e.g., myocardial ischemia)
Correction of Clotting Disorder
Patients with GIB should be evaluated for an underlying coagulopathy as is commonly seen in liver disease or warfarin therapy. In the setting of active bleeding and an elevated prothrombin time (PT), fresh frozen plasma should be administered as the most rapid means of correction. Vitamin K can also be given for an elevated PT. Heparin and, to a lesser extent enoxaparin, can be reversed with protamine. Both will also respond to fresh frozen plasma.
A platelet transfusion should be performed in patients with severe GIB and a platelet count less than 50,000/ml. It may also be considered in patients with severe GIB and presumed platelet dysfunction from aspirin or clopidogrel use.
The differential diagnosis of GIB is divided into upper and lower sources. A list of critical diagnoses includes:
Upper GIB Ddx
- Gastric and duodenal ulcer
- Gastritis and esophagitis
- Esophageal and gastric varices
- Mallory-Weiss tear
- Aortoenteric fistula
Lower GIB DDx
- Colitis (infectious, ischemic, inflammatory bowel disease)
- Anorectal (hemorrhoids, fissures)
The specific disease section on GIB will provide further discussion on the presentation, diagnostics, and specific treatments for causes of upper and lower GIB. The emphasis will be on the evaluation and management of massive GIB.