Gastroenterology
GI Bleeding (Upper & Lower)
Gastroenterology

GI Bleeding (Upper & Lower)

Resuscitate → EGD/colonoscopy; variceal bleed bundle.

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◆Upper vs Lower GI bleed

  • •Upper (proximal to ligament of Treitz): hematemesis (bright red or coffee-ground) or melena
  • •Causes: PUD (esp. duodenal eroding into gastroduodenal artery), varices, Mallory-Weiss
  • •Gold standard diagnostic/therapeutic: EGD
  • •Lower (distal to Treitz): hematochezia (painless BRBPR)
  • •Causes: diverticulosis (#1 in older adults), angiodysplasia, CRC, IBD
  • •First-line: colonoscopy

◆Initial stabilization

  • •Two large-bore IVs
  • •Isotonic crystalloids (NS or LR)
  • •Transfuse: Hgb <7 stable; lower threshold if ongoing hemorrhage/end-organ dysfunction
  • •Intubate if massive hematemesis or AMS for airway protection

◆Variceal hemorrhage bundle

  • •Octreotide IV (↓splanchnic flow + portal pressure)
  • •Ceftriaxone IV (↓ SBP risk; improves mortality)
  • •Urgent EGD within 12 hr — band ligation or sclerotherapy
  • •Refractory: balloon tamponade (Sengstaken-Blakemore) as bridge → TIPS
  • •Prevention: nonselective BB (propranolol/nadolol) or EVL for newly diagnosed cirrhosis

◆Anorectal bleeding

  • •Anal fissure: severe pain with defecation + BRBPR on TP; posterior midline; sitz baths + fiber + topical nifedipine/nitroglycerin
  • •Internal hemorrhoids: painless BRBPR (above pectinate line)
  • •External hemorrhoids: pain only if thrombosed
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