CAUSES

Anal lesions (hemorrhoids, fissures), rectal trauma, proctitis, colitis (ulcerative colitis, Crohn’s disease, infectious colitis, ischemic colitis, radiation), colonic polyps, colonic carcinoma, angiodysplasia (vascular ectasia), diverticulosis, intussusception, solitary ulcer, blood dyscrasias, vasculitis, connective tissue disease, neurofibroma, amyloidosis, anticoagulation.

EVALUATION

• History and physical examination (see below and Fig. 43-2).
• In the presence of hemodynamic changes, perform upper endoscopy followed by colonoscopy. In the absence of hemodynamic changes, perform anoscopy and either flexible sigmoidoscopy or colonoscopy: Exclude hemorrhoids, fissure, ulcer, proctitis, neoplasm.
• Colonoscopy: Often test of choice, but may be impossible if bleeding is massive.
• Barium enema: No role in active bleeding.
• Arteriography: When bleeding is severe (requires bleeding rate >0.5 mL/min; may require prestudy radioisotope bleeding scan as above); defines site of bleeding or abnormal vasculature.
• Surgical exploration (last resort).

FIGURE 43-2

Suggested algorithm for pts with acute lower GI bleeding.

BLEEDING OF OBSCURE ORIGIN

Often small-bowel source. Consider small-bowel enteroclysis x-ray (careful barium radiography via peroral intubation of small bowel), Meckel’s scan, enteroscopy (small-bowel endoscopy), or exploratory laparotomy with intraoperative enteroscopy.

Treatment: Upper and Lower GI Bleeding

• Venous access with large-bore IV (14–18 gauge); central venous line for major bleed and pts with cardiac disease; monitor vital signs, urine output, Hct (fall may lag). Gastric lavage of unproven benefit but clears stomach before endoscopy. Iced saline may lyse clots; room-temperature tap water may be preferable. Intubation may be required to protect airway.
• Type and cross-match blood (six units for major bleed).
• Surgical standby when bleeding is massive.
• Support blood pressure with isotonic fluids (normal saline); albumin and fresh frozen plasma in cirrhotics. Packed red blood cells when available (whole blood if massive bleeding); maintain Hct >25–30. Fresh frozen plasma and vitamin K (10 mg SC or IV) in cirrhotics with coagulopathy.
• IV calcium (e.g., up to 10–20 mL 10% calcium gluconate IV over 10–15 min) if serum calcium falls (due to transfusion of citrated blood). Empirical drug therapy (antacids, H₂ receptor blockers, omeprazole) of unproven benefit.
• Specific measures: Varices: octreotide (50-µg bolus, 50-µg/h infusion for 2–5 days), Sengstaken-Blakemore tube tamponade, endoscopic sclerosis, or band ligation; propranolol or nadolol in doses sufficient to cause beta blockade reduces risk of recurrent or initial variceal bleeding (do not use in acute bleed) (Chap. 158: Portal Hypertension); ulcer with visible vessel or active bleeding: endoscopic bipolar, heater-probe, or laser coagulation or injection of epinephrine; gastritis: embolization or vasopressin infusion of left gastric artery; GI telangiectases: ethinylestradiol/norethisterone (0.05/1.0 mg PO qd) may prevent recurrent bleeding, particularly in pts with chronic renal failure; diverticulosis: mesenteric arteriography with intraarterial vasopressin; angiodysplasia: colonoscopic bipolar or laser coagulation, may regress with replacement of stenotic aortic valve.
• Indications for emergency surgery: Uncontrolled or prolonged bleeding, severe rebleeding, aortoenteric fistula. For intractable variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS).

Outline

• Gastrointestinal Bleeding
  • PRESENTATION
  • UPPER GI BLEEDING
  • LOWER GI BLEEDING