SHM's Clinical Quick Talks-Gastrointestinal Bleed

Pdf Summary

This teaching script on Gastrointestinal Bleeding (GIB) outlines key clinical distinctions and management strategies. The ligament of Treitz anatomically separates upper GIB (UGIB) from lower GIB (LGIB). UGIB often presents with hematemesis or melena, while LGIB typically causes hematochezia, though brisk UGIB can also present with hematochezia.<br /><br />Causes of UGIB (accounting for 70-80% of cases) include esophageal varices related to alcohol use and liver disease; esophagitis from infections, medications, or reflux; Mallory-Weiss tears following vomiting or alcohol abuse; neoplasms; and stomach/duodenal conditions like peptic ulcer disease (PUD), gastritis, Dieulafoy lesions, neoplasms, and aortoenteric fistula. Risk factors such as NSAID use, H. pylori infection, and history of radiation or immunosuppression guide diagnosis.<br /><br />LGIB (20-30%) causes include diverticular bleeding, angiodysplasia (noted in CKD, cardiovascular disease, aortic stenosis), ischemic and inflammatory colitis, infectious colitis due to pathogens like Campylobacter and EHEC, neoplasms, and hemorrhoids or fissures.<br /><br />Management prioritizes stabilization: securing two large-bore IVs, blood typing and consent, fluid and blood transfusions aiming for hemoglobin ≥7 g/dL (or 8 g/dL in active coronary artery disease), IV proton pump inhibitors if UGIB suspected, and octreotide for esophageal varices. Endoscopy remains the gold standard for diagnosis and therapy through techniques like cautery, banding, or clipping. In unstable patients, CT angiography and interventional radiology embolization are options. Additional scopes can be employed if bleeding source is unclear.<br /><br />A major clinical challenge is timing anticoagulation resumption after GIB. While restarting anticoagulants or antiplatelets may raise bleeding risk, evidence supports reduced thromboembolism and mortality when resumed appropriately. Recommendations suggest 3 days for high thrombotic risk and 7–30 days otherwise, tailored individually.<br /><br />Clinical pearls emphasize recognizing typical presentations, resuscitation protocols, and individualized anticoagulation decisions. This concise framework aids optimal care for patients admitted with suspected gastrointestinal bleeding.

Asset Subtitle

Marilyn Marshall

Keywords

Gastrointestinal bleeding

Upper gastrointestinal bleeding

Lower gastrointestinal bleeding

Ligament of Treitz

Esophageal varices

Peptic ulcer disease

Diverticular bleeding

Endoscopy

Anticoagulation management

Hemodynamic stabilization