The anatomical landmark that separates the upper and lower hemorrhages is the ligament of Treitz, also known as the duodenal suspension. This peritoneal structure keeps the duodenojejunal bend away from the retroperitoneum....
Introduction
Gastrointestinal bleeding falls into two broad categories:
Upper and lower bleeding sources
The anatomical landmark that separates the upper and lower hemorrhages is the ligament of Treitz, also known as the duodenal suspension. This peritoneal structure keeps the duodenojejunal bend away from the retroperitoneum. Bleeding from above the ligament of Treitz usually manifests as hematemesis or melena, while bleeding from below most commonly manifests as blood in the stool.
The regurgitation of blood or blood combined with stomach contents is known as hemoptysis. Melena is black, dark, tarry feces, typically with a strong characteristic odor, caused by the action of digestive enzymes and intestinal bacteria on hemoglobin. Hematochezia is bright red blood passing through the rectum.
Examination
Upper gastrointestinal (GI) and lower gastrointestinal bleeding are the two types of gastrointestinal bleeding that can occur.
Bleeding in the upper gastrointestinal tract
- Peptic ulcer disease (which may be secondary to excess stomach acid, H. pylori infection, Nsaid overuse, or physiological stress)
- Esophagitis
- Gastritis and duodenal inflammation
- Varicose vein
- Portal hypertensive gastritis ()
- Angiodysplasia
- A lesion is a hemorrhagic, dilated blood vessel that erodes the gastrointestinal epithelium but is not a primary ulcer; It could happen any place in the digestive system.
- Sinus ectasia (gab; also known as watermelon stomach)
- Mallory White Tears
- Cameron's lesion (a bleeding ulcer that develops at the site of a hiatus hernia)
- Aortoenteric fistula
- Ingestion of foreign objects
- Postoperative bleeding (post-anastomosis bleeding, post-polypectomy bleeding, and post-sphincterotomy bleeding)
- upper gastrointestinal tumor
- Hematoma (bleeding from the bile ducts)
- Pancreatic Hemosuccus (bleeding from the pancreatic duct)
Lower gastrointestinal bleeding
- Diverticulosis (protrusion of the intestinal wall when blood vessels are inserted); over time, the mucosa overlying the vessel can be injured and rupture, leading to bleeding) [diverticulosis]
- Angiodysplasia
- Infectious colitis
- Ischemic colitis
- Inflammatory bowel disease
- Colon cancer
- Hemorrhoids
- Anal fissures
- Rectal varices
- Lesion (more rarely found outside of the stomach, although can be found throughout the GI system) (more rarely found outside of the stomach, but can be found throughout the GI tract)
- Damage caused by radiation after undergoing treatment for stomach or pelvic cancer.
- Post-surgical (post-polypectomy bleeding, post-biopsy bleeding)
Causes
Various medical conditions can cause bleeding in the gastrointestinal tract. Lower gastrointestinal haemorrhage can have a variety of causes.
Peptic ulcer: Peptic ulcer disease is frequently brought on by Helicobacter pylori (H. pylori) infection and chronic use of non-steroidal anti-inflammatory medicines (NSAIDs), including aspirin and ibuprofen.
Esophageal varices: Varicose veins, or dilated veins, at the bottom of the esophagus can rupture and bleed profusely. Esophageal varices are most frequently caused by cirrhosis.
Mallory Weiss Tears: These tears lining of the esophagus are usually caused by vomiting. Increased abdominal pressure from coughing, hiatus hernia, or childbirth can also lead to tears.
Esophagitis: The most frequent cause of esophagitis and ulcers on the esophageal lining is gastroesophageal reflux disease (GERD). In GERD, the muscle when the valve that should be closing properly between the esophagus and stomach food and gastric juices to flow back up into the esophagus.
Benign tumors and cancer: benign tumours are abnormal tissue growths that are not cancerous. Benign tumours and cancers of the esophagus, stomach, or duodenum can cause bleeding.
Causes of lower gastrointestinal bleeding include
Diverticulosis: This disease is caused by diverticular pockets in the colon wall. colitis. Infections, diseases such as Crohn's disease, colon inflammation, or colitis, can be brought on by radiation and a lack of blood supply to the colon.
Hemorrhoids or fissures: Hemorrhoids are dilated veins in the anus or rectum that can rupture and bleed. A fissure or ulcer is a cut or tear in the anal area.
Angiodysplasia: Ageing causes angiodysplasia—abnormalities of blood vessels in the intestine.
Benign growths or polyps: in the colon are frequent and can develop into cancer. The third most frequent disease in the US is colon cancer, which frequently causes occult blood.
Epidemiology
More frequently than lower gastrointestinal bleeding occurs upper gastrointestinal bleeding (UGIB) (LGIB). The incidence of UGIB is approximately 67 per 100,000 people, while the incidence of LGIB is approximately 36 per 100,000 people. Men are more likely than women to have vascular disease and diverticulosis, which makes LGIB more prevalent in men. The incidence increases with age. Overall incidence rates are declining nationwide.
History and Physical
History:
Question the patient for potential clues regarding:
- previous episodes of GI bleeding
- historical medical data relevant to the likely causes of bleeding (e.g., varices, portal hypertension, alcohol abuse, tobacco abuse, ulcers.
- Comorbid conditions that could affect management.
- confusing or contributing medications (non-steroidal anti-inflammatory drugs, anticoagulants, antiplatelet agents, bismuth, iron)
- symptoms and indicators of bleeding (For instance, discomfort against discomfort, difficulty swallowing, unintended weight loss, preceding emesis or retching, change in bowel habits, etc.)
Physical:
Look for signs of hemodynamic instability:
- Resting tachycardia—associated with the loss of less than 15% total blood volume.
- orthostatic hypotension and a 15% reduction in total blood volume.
- Supine hypotension—associated with the loss of approximately 40% of total blood volume.
- Perforation or ischemia may be suspected if there is abdominal pain. Rectal examinations are crucial for assessing:
1.Anal fissure
2.Hemorrhoid
3.Anorectal mass
4.Stool test
Evaluation
The following laboratory tests are recommended to determine the cause of gastrointestinal bleeding:
- Complete blood count
- Hemoglobin/hematocrit
- International normalized ratio (INR), prothrombin time, activated partial thromboplastin time
- Lactic acid
- Liver function test
- Diagnostic studies
Upper GI endoscopy
- can be both diagnostic and therapeutic.
- allows for visibility of the upper GI tract and treatment with injectable therapy, heat coagulation, or hemostatic clips or bands (usually from the mouth cavity up to the duodenum).
Lower GI endoscopy or colonoscopy
- can be both diagnostic and therapeutic.
- allows for treatment with injectable therapy, thermal coagulation, or hemostatic clips or bands as well as visualization of the colon and terminal ileum are both parts of the lower GI tract.
Push enterostomy.
- allows for increased small bowel visualization.
Deep small bowel enterostomy
- allows for increased small bowel visualization.
- Nuclear scintigraphy
- Tagged rbc scan.
- uses technetium-99m to detect bleeding that is happening at a rate of 0.1 to 0.5 ml/min (can only detect active bleeding)
CT angiography
- enables the detection of a bleeding vessel that is active.
Standard angiography
- enables the detection of a bleeding vessel and potential embolization or intra-arterial vasopressin therapy.
- requires a rate of 0.5 to 1.0 ml/min for vigorous bleeding in order to see the location.
Meckel scan
- A nuclear medicine scan to look for ectopic gastric mucosa.
Management
The conventional approach to the acute management of GI bleeding entails determining the best setting for care, followed by resuscitation and supportive therapy while looking into the underlying cause and trying to address it.
Risk Stratification
Several risk calculators stratify patients based on their mortality risk to identify those who would benefit from ICU level of care. The fatality rate of upper GI bleeding is calculated using the AIMS65 score and the Rockfall score. Two different Rockfall scores exist.
Before to endoscopy, one score determines pre-endoscopy mortality, but after endoscopy, the second score determines total mortality and re-bleeding risks. A risk calculator called the Oakland Score aims to determine the likelihood of a safe discharge in cases of lower GI bleeding.
Situation
ICU
A patient should be monitored in an intensive care unit if they have hemodynamic instability, persistent bleeding, or are at high risk of morbidity or fatality. This will allow for more regular monitoring of their vital signs and more urgent therapeutic action.
General medicine department
Most other patients can be monitored on the general care floor. However, continuous telemetry monitoring may be helpful for the early detection of hemodynamic compromise.
Outpatient
Most patients with gastrointestinal bleeding require hospitalization. However, some young, healthy patients with self-limiting, asymptomatic bleeding can be safely discharged and evaluated as outpatients.
Treatment
- Nothing above the mouth
- Those who are hypoxic receive additional oxygen (usually with a nasal cannula, but people with persistent hematemesis or altered mental status may need to be intubated). The danger of aspiration from prolonged vomiting should be avoided when using noninvasive positive pressure ventilation (NIPPV).
- Adequate IV access—at least two large-diameter (18 gauge or larger) peripheral IVs or one centrally placed.
- IV fluid ventilation (using saline or lactated Ringer's solution)
- Blood type and crossmatch
- Transfusion
Red blood cell transfusion
- It typically begins in people with coronary artery disease when their hemoglobin falls below 7 g/dL.
Platelet transfusion
- Start when platelet count <50,000/μl
Prothrombin complex concentrate
- Blood transfusion if INR > 2
Medication
PPI
- used experimentally for upper GI bleeds; after the source of the bleeding has been found, treatment may be continued or discontinued.
Prokinetic agents
- administered to enhance visibility during endoscopy.
Vasoactive medications
- Somatostatin and its analogue, octreotide, can be used to treat variceal bleeding by inhibiting vasodilatory hormone release.
Antibiotics
- prophylactically considered in cirrhotic patients to prevent translocation, especially from endoscopy
Anticoagulant/antiplatelet agents
- If at all feasible, cease if there are acute bleeding.
- Consider the reversal of agents on a case-by-case basis, depending on the severity of the bleeding and the risks of reversal.
Other
If removing clots or fresh blood is required to facilitate endoscopy, think about NGT lavage:
In patients with hemodynamic instability/massive GI bleeds in the presence of known varices, the placement of a Blakemore or Minnesota tube should be taken into consideration. Only when the airway has been protected should this be done. Only an expert should do this procedure. practitioner as a temporary measure because it entails a high risk of complications (including arrhythmias, gastric or esophageal perforation).
Patients with significant bleeding or hemodynamic instability who have bleeding that is resistant to other treatments should seek surgery as soon as possible.
Colonoscopy with bipolar probe coagulation, epinephrine injection, or metal clips are employed in the event of diverticular bleeding.
Thermal therapy should be used if lower GI bleeding is caused by angiodysplasia.
Differential diagnosis
Few diagnoses mimic gastrointestinal bleeding. Occasionally, hemoptysis is confused with hematemesis. Consuming products containing bismuth or iron supplements can cause stools to appear melanin-like. Certain foods and dyes can stain vomit and stool red, purple, or maroon (e.g., beets). Other differences to consider in gastrointestinal bleeding are:
Upper gastrointestinal bleeding
- Gastric ulcer
- Esophagitis
- Gastritis and duodenitis
- Varicose vein
- Portal hypertensive gastropathy
- Angiodysplasia
- Durafoy lesion
- Sinus valve ectasia
- Mallory Weiss Tears
- Cameron's lesion
- Aortoenteric fistula
- Ingestion of foreign objects
- Upper gastrointestinal tumor
- Haemobilia
- Hemosuccus pancreaticus
Lower gastrointestinal bleeding
- Diverticulosis
- Angiodysplasia
- Infectious colitis
- Ischemic colitis
- Inflammatory bowel disease
- Colon cancer
- Hemorrhoid
- Anal fissure
- Rectal varicose veins
- Durafoy lesion
- Radiation-induced colitis
Prevention
To prevent gastrointestinal bleeding:
- Use non-steroidal anti-inflammatory medicines only as necessary.
- Limit your alcohol consumption.
- If you smoke, quit.
- If you have GERD, treat it as directed by your doctor.
Prognosis
Studies on the prognosis after gastrointestinal bleeding are limited.
In observational studies, the in-hospital mortality rate for upper gastrointestinal bleeding is approximately 10%. This rate remains constant up to 1 month after hospitalization for gastrointestinal bleeding. Long-term follow-up of a patient with UGIB shows that 3 years after his admission,
all-cause mortality approaches 37%.
When adjusted for age, mortality is higher in women than in men, which is different from less gastrointestinal bleeding. Patients who are hospitalized multiple times for gastrointestinal bleeding have a higher mortality rate. The long-term prognosis was worst in patients suffering from malignant tumors and variceal bleeding. The prognosis worsened with aged.
For lower gastrointestinal bleeding, all-cause in-hospital mortality is low, less than 4%. Deaths from LGIB itself are rare, and most in-hospital deaths are due to other comorbidities. Increased mortality risk corresponds to ageing (as in UGIB), comorbidities, and intestinal ischemia.
Other negative prognostic factors are secondary bleeding (onset of bleeding after being hospitalized for another condition), patients with pre-existing coagulopathy, hypovolemia, the need for blood transfusions, and male sex. Not surprisingly, the lowest mortality risk is associated with more benign causes of his LGIB, such as hemorrhoids, anal fissures, and colonic polyps. Long-term follow-up studies of LGIB patients are uncommon.
Complications
Gastrointestinal bleeding can have serious consequences if not treated in a timely or appropriate manner. The following complications may occur in patients bleeding from the upper or lower gastrointestinal tract.
- Respiratory disease
- Heart attack
- Infection
- Shock
- Death
