LGIH Lower Gastrointestinal Hemorrhage
Gastrointestinal bleeding or gastrointestinal hemorrhage describes every form
of hemorrhage (loss of blood) in the gastrointestinal tract, from the pharynx to
the rectum. It has diverse causes, and a medical history, as well as physical
examination, generally distinguishes between the main forms. The degree of
bleeding can range from nearly undetectable to acute, massive, life-threatening
bleeding.
Initial emphasis is on resuscitation by infusion of intravenous fluids and blood
transfusion, treatment with proton pump inhibitors and occasionally with
vasopressin analogues and tranexamic acid. Upper endoscopy or colonoscopy are
generally considered appropriate to identify the source of bleeding and carry
out therapeutic interventions.
Symptoms and signs
Gastrointestinal bleeding can range from microscopic bleeding, where the amount
of blood is so small that it can only be detected by laboratory testing (in the
form of iron deficiency anemia), to massive bleeding where pure blood is passed
and hypovolemia and shock may develop, risking death.
Classification
Gastrointestinal bleeding can be roughly divided into two clinical syndromes.
Upper gastrointestinal bleeding
Main article: upper gastrointestinal bleeding
Upper gastrointestinal bleeding is from a source between the pharynx and the
ligament of Treitz. An upper source is characterised by hematemesis (vomiting up
blood) and melena (tarry stool containing altered blood).
Lower gastrointestinal bleeding
Main article: Lower gastrointestinal bleeding
Lower gastrointestinal bleeding may be indicated by red blood per rectum,
especially in the absence of hematemesis. Isolated melena may originate from
anywhere between the stomach and the proximal colon.
Treatment
Early management
Initial focus in any patient with a form of gastrointestinal hemorrhage is on
resuscitation, as any further intervention is precluded by the presence of
intravascular depletion or shock.
Fluid resuscitation: intravenous fluids and blood transfusion may be
administered.
Acid suppression: in an upper GI source, proton pump inhibitors reduce gastric
acid production and enhance healing of bleeding lesions.
Inhibition of fibrinolysis: in ongoing bleeding, tranexamic acid reduces
fibrinolysis and may decrease blood product requirements.
Correction of coagulopathy: if coagulation parameters (e.g. prothrombin time)
are deranged, vitamin K or fresh frozen plasma may need to be administered.
Reduction of portal pressure: if the bleeding is thought to be due to esophageal
varices (a complication of cirrhosis of the liver), vasopressin analogues and
rarely octreotide may be administered. Rarely, a Sengstaken-Blakemore tube may
be inserted to mechanically compress varices.
Urgent endoscopy: if the bleeding cannot be managed medically an urgent
esophagogastroduodenoscopy (EGD/OGD) may identify sources of bleeding. This is a
high-risk procedure best performed under safe circumstances in the intensive
care unit or operating theatres.
Surgical intervention: in extreme cases of bleeding, laparotomy may be required
to identify the bleeding source.
Endoscopy
After adequate stabilization, endoscopy (upper endoscopy and/or colonoscopy) are
used to identify the source of bleeding. Injection, sclerotherapy,
electrocoagulation, vascular clipping and biopsy may be performed.
Endoscopy is also useful in setting the indication for therapy, e.g. the need
for long-term proton pump inhibitor therapy, presence of esophageal varices,
adenomatous polyps and so on.