Gastrointestinal Bleeding

Gastrointestinal Bleeding is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • Bleeding from GI tract:
    • Upper GI tract: Proximal to ligament of Treitz
    • Lower GI tract: Distal to ligament of Treitz to anus
  • Mortality rate:
    • 10% overall; from <5% in children up to 25% for adults age >70
    • Upper GI bleed (UGIB) 6–8%
      • Variceal 30–50%
    • Lower GI bleed (LGIB) 2–4%

Etiology

Upper GI Bleed (UGIB):
  • Ulcerative disease of upper GI tract:
    • Peptic ulcer disease (40%):
      • Helicobacter pylori infection
      • Drug-induced (NSAIDs, aspirin, glucocorticoids, K+ supplements, Fe supplements)
    • Gastric or esophageal erosions (25%):
      • Reflux esophagitis
      • Infectious esophagitis (Candida, HSV, CMV)
      • Pill-induced esophagitis
      • Esophageal foreign body
    • Gastritis and stress ulcerations:
      • Toxic agents (NSAIDs, alcohol, bile)
      • Mucosal hypoxia (trauma, burns, sepsis)
      • Cushing ulcers from severe CNS damage
      • Chemotherapy
  • Portal HTN:
    • Esophageal or gastric varices (10%)
    • Portal hypertensive gastropathy
  • Arteriovenous malformations:
    • Aortoenteric fistula (s/p aortoiliac surgery)
    • Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu syndrome)
    • Dieulafoy vascular malformations
    • Gastric antral vascular ectasia (GAVE or watermelon stomach)
    • Idiopathic angiomas
  • Mallory–Weiss tear (5%)
  • Gastric and esophageal tumors
  • Pancreatic hemorrhage
  • Hemobilia
  • Strongyloides stercoralis infection

Lower GI Bleed (LGIB):
  • Diverticulosis (33%)
  • Cancer or polyps (19%)
  • Colitis (18%):
    • Ischemic, inflammatory, infectious, or radiation
  • Vascular (8%):
    • Angiodysplasia
    • Radiation telangiectasia
    • Aortocolonic fistula
  • Inflammatory bowel disease:
    • Crohn disease and ulcerative colitis
  • Postpolypectomy
  • Anorectal (4%):
    • Hemorrhoids (internal and external)
    • Anal fissures
    • Anorectal varices
    • Rectal ulcer
    • Foreign body

Pediatric Considerations
Meckel diverticulum and intussusception are the most common causes of LGIB in children

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Basics

Description

  • Bleeding from GI tract:
    • Upper GI tract: Proximal to ligament of Treitz
    • Lower GI tract: Distal to ligament of Treitz to anus
  • Mortality rate:
    • 10% overall; from <5% in children up to 25% for adults age >70
    • Upper GI bleed (UGIB) 6–8%
      • Variceal 30–50%
    • Lower GI bleed (LGIB) 2–4%

Etiology

Upper GI Bleed (UGIB):
  • Ulcerative disease of upper GI tract:
    • Peptic ulcer disease (40%):
      • Helicobacter pylori infection
      • Drug-induced (NSAIDs, aspirin, glucocorticoids, K+ supplements, Fe supplements)
    • Gastric or esophageal erosions (25%):
      • Reflux esophagitis
      • Infectious esophagitis (Candida, HSV, CMV)
      • Pill-induced esophagitis
      • Esophageal foreign body
    • Gastritis and stress ulcerations:
      • Toxic agents (NSAIDs, alcohol, bile)
      • Mucosal hypoxia (trauma, burns, sepsis)
      • Cushing ulcers from severe CNS damage
      • Chemotherapy
  • Portal HTN:
    • Esophageal or gastric varices (10%)
    • Portal hypertensive gastropathy
  • Arteriovenous malformations:
    • Aortoenteric fistula (s/p aortoiliac surgery)
    • Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu syndrome)
    • Dieulafoy vascular malformations
    • Gastric antral vascular ectasia (GAVE or watermelon stomach)
    • Idiopathic angiomas
  • Mallory–Weiss tear (5%)
  • Gastric and esophageal tumors
  • Pancreatic hemorrhage
  • Hemobilia
  • Strongyloides stercoralis infection

Lower GI Bleed (LGIB):
  • Diverticulosis (33%)
  • Cancer or polyps (19%)
  • Colitis (18%):
    • Ischemic, inflammatory, infectious, or radiation
  • Vascular (8%):
    • Angiodysplasia
    • Radiation telangiectasia
    • Aortocolonic fistula
  • Inflammatory bowel disease:
    • Crohn disease and ulcerative colitis
  • Postpolypectomy
  • Anorectal (4%):
    • Hemorrhoids (internal and external)
    • Anal fissures
    • Anorectal varices
    • Rectal ulcer
    • Foreign body

Pediatric Considerations
Meckel diverticulum and intussusception are the most common causes of LGIB in children

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