Background Information

Definition

Upper vs lower GI bleed is an anatomical definition:

• Upper GI bleed: bleeding that originates from a source proximal to the ligament of Treitz (duodenal-jejunal ligament)
• Lower GI bleed: source distal to the ligament of Treitz

Aetiology

Upper and lower GI bleeding causes (adults mainly): ^{[Ref1][Ref2][Ref3]}

	Upper GI bleeding	Lower GI bleeding
Important causes	Peptic ulcer disease – most common cause Oesophagitis / gastritis / duodenitis (erosive disease) Oesophageal / gastric varices Mallory-Weiss tears (mucosal lacerations at the GOJ, typically after episodes of forceful retching or vomiting) (often in the context of alcohol use) Upper GI malignancy	Diverticular bleeding – most common cause Haemorrhoids / anal fissure Colorectal cancer / polyps Colitis Ulcerative colitis > Crohn’s disease Ischaemic colitis Infectious colitis (e.g. Campylobacter)
Rarer causes	Dieulafoy’s lesion (an abnormally large submucosal artery that fails to taper normally and erodes through the gastric mucosa) (it can cause sudden, severe bleeding without preceding symptoms) Gastric antral vascular ectasia (GAVE) (dilated blood vessels in the gastric antrum, arranged in longitudinal red stripes, that give a watermelon appearance) Aorto-enteric fistula (rare but can cause catastrophic bleeding) (suspect in those after aortic aneurysm repair presenting with upper GI bleed)	Rectal ulcer Radiation proctitis Heyde syndrome (triad of aortic stenosis + acquired vWF deficiency + GI bleeding from angiodysplasia)
Shared causes	Antiplatelet / anticoagulant use NSAIDs use Coagulopathies Vascular ectasia (angiodysplasia)

Some paediatric-specific causes of GI bleeding:

Necrotising enterocolitis	In premature neonates Distended abdomen Feeding intolerance Unwell neonate
Meckel’s diverticulum	In <2 y/o Painless lower GI bleed (large volume) Often requires transfusion
Intussusception	In 6-18 m/o Triad of colicky abdominal pain + palpable sausage-shaped mass + red currant jelly stools (late sign)
Inflammatory bowel disease (ulcerative colitis > Crohn’s disease)	In adolescents

Clinical Features

Presentation of upper vs lower GI bleeding: ^[Ref1][Ref2]

Upper GI bleeding	Lower GI bleeding
Common presentation: Haematemesis (vomiting of bright red blood / coffee-ground vomit) Melena (black, tarry, foul-smelling stools – due to digested blood) Rarely, severe upper GI bleeding can cause haematochezia	Presents as haematochezia (passage of fresh blood per rectum) Colonic bleeding Blood mixed with stool Blood is more dark red Rectal bleeding Streaks of blood coating the outside of the stool / blood on toilet paper / drips into the bowel after defecation Blood is more bright-red

Non-specific features of bleeding:

• Tachycardia
• Orthostatic hypotension
• Pre-syncope

Assessment

Risk Assessment

NICE recommends the following scores to stratify patients:

• Glasgow-Blatchford score at first assessment (before endoscopy, Blatchford = Before), and
• Rockall score (complete) after endoscopy

Work-Up

A standard work-up for acute GI bleed would include:

• CBC, U&E, LFT
• Coagulation tests – PT/INR, APTT
• Blood type and crossmatch

Management

Consider early discharge in those with a pre-endoscopy Blatchford score of 0.

Initial Management

A-E approach:

• Consider intubation to protect the airway (e.g. in patients with ongoing haematemesis and altered mental status)
• Gain IV access and start IV fluid resuscitation
• Transfuse and reverse anticoagulation accordingly (see below)

Transfusion Thresholds

Various transfusion thresholds:

Component	Cut-off
Whole blood	Haemoglobin <70 g/L
Platelet	Platelet count <50 x 109 /L + actively bleeding
Fresh frozen plasma	PT (or INR) or APTT >1.5x normal
Cryoprecipitate	Fibrinogen level <1.5 g/L despite fresh frozen plasma
Recombinant factor VIIa	Only considered if all other methods have failed

Anticoagulation Reversal

Anticoagulant	Reversal agent
Heparin	Protamine sulfate (fully effective for UFH, but only partial reversal for LMWH)
Warfarin	Prothrombin complex concentrate (only consider fresh frozen plasma as 2nd line) + IV vitamin K
Dabigatran	Idarucizumab
Apixaban and rivaroxaban	Andexanet alfa

Definitive Management

Definitive management is endoscopic haemostasis

• Unstable patients → resuscitate, then immediate endoscopy (once stabilised)
• Stable patients → endoscopy within 24 hours after admission

 

Endoscopic management depends on the source of bleeding.

Non-Variceal Bleeding

Offer one of the following for endoscopic haemostasis:

• Mechanical method (e.g. clip) +/- adrenaline
• Thermal coagulation with adrenaline
• Fibrin / thrombin with adrenaline

Post-endoscopy PPI is recommended if there are signs of recent or active bleeding at endoscopy (reduces risk of rebleeding and need for surgery)

• NICE specifically recommends AGAINST routine pre-endoscopic PPI (as it makes endoscopic bleeding less visible and does not improve key clinical outcomes like rebleeding, need for surgery and mortality)

Variceal Bleeding

Pre-endoscopic management (in addition to resuscitation) for ALL suspected variceal bleeding:

• Terlipressin (stop after 5 days or after definitive haemostasis), and
• Prophylactic antibiotic

 

Definitive management: endoscopic interventions:

• Oesophageal varices → band ligation
• Gastric varices → cyanoacrylate glue injection (chemical ligation)

 

If endoscopic measures failed → transjugular intrahepatic portosystemic shunt (TIPS)

• A radiological procedure where a mental stent is placed to create a shunt between the portal vein and hepatic vein (accessed via the jugular vein)
• Blood bypasses the cirrhotic liver → reducing portal pressure

Post-Acute Variceal Bleeding (Secondary Prophylaxis)

Offer all the following:

• Carvedilol
• Variceal band ligation every 4 weeks until eradication
• Surveillance upper GI endoscopy

References