What are the causes of Gastrointestinal (GI) bleed?

From the Guidelines

GI bleeding is a serious medical condition requiring immediate medical attention, and treatment depends on the location and severity of bleeding, with initial management including IV fluid resuscitation, blood transfusions, and proton pump inhibitors, as well as endoscopy or colonoscopy to identify and potentially treat the bleeding source 1.

Key Considerations

• The incidence of nonvariceal upper gastrointestinal bleeding is approximately 61 to 78 cases per 100,000 persons in the United States, with an estimated mortality of 2% to 10% 1.
• Peptic ulcer disease caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drug use is the most common cause of non-variceal upper GI bleeding 1.
• For upper GI bleeds, initial management includes IV fluid resuscitation, blood transfusions if hemoglobin is below 7-8 g/dL, and proton pump inhibitors (PPI) such as pantoprazole 40mg IV twice daily or esomeprazole 40mg IV twice daily 1.
• Endoscopy should be performed within 24 hours to identify and potentially treat the bleeding source, as it is the usual first-line diagnostic and therapeutic investigation for nonvariceal upper GI bleeding 1.

Management of GI Bleeding

• In cases of massive bleeding, octreotide 50mcg IV bolus followed by 50mcg/hour infusion may help reduce bleeding from varices 1.
• Patients with liver disease and varices may require prophylactic antibiotics like ceftriaxone 1g IV daily 1.
• After acute management, patients typically transition to oral PPIs (omeprazole 20mg daily) for 4-8 weeks 1.

Important Considerations

• GI bleeding can be life-threatening because blood loss can lead to hypovolemic shock, and the presence of blood in the GI tract can cause complications like aspiration or bacterial translocation, making prompt diagnosis and treatment essential 1.
• The management of lower gastrointestinal bleeding is also crucial, with diverticulosis, angiodysplasia, hemorrhoids, and ischemic colitis being common causes of lower GI bleeding 1.

From the Research

Diagnosis and Management of GI Bleed

• The diagnosis and management of gastrointestinal (GI) bleeding require a prompt and accurate approach to prevent end-organ injury and manage comorbid illnesses 2.
• The goals of care for GI bleeding include identifying the source of bleeding, stopping continued bleeding, supporting oxygen-carrying capacity, and preventing rebleeding 2.
• Upper GI bleeding is a common medical emergency with a reported mortality of 2-10%, and patients identified as being at very low risk can be managed as outpatients 3.

Treatment Options

• Intravenous fluids and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended for patients with upper GI bleeding 3.
• Proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered after resuscitation is initiated 3.
• Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk 3.
• Endoscopic treatment is used for variceal bleeding and for high-risk non-variceal bleeding 3.

Prehospital Transfusion

• Prehospital transfusion of packed red blood cells (pRBC) and/or plasma may benefit patients with acute GI bleeding by correcting coagulopathy and anemia 4.
• Patients who received prehospital transfusion had a significant increase in hemoglobin and decrease in INR compared to those who did not receive transfusion 4.

Endoscopic Management

• Early endoscopy is recommended for diagnosis and treatment of peptic ulcer bleeding, with endoscopic therapy indicated for patients with high-risk stigmata 5.
• Ablative or mechanical therapies are superior to epinephrine injection alone in terms of prevention of rebleeding 5.
• High-dose proton pump inhibitors should be administered intravenously for 72 hours after endoscopy in high-risk patients 5.

Clinical Approach

• The optimal management of acute GI bleeding requires a timely overview of vital signs and clinical presentation to stabilize the patient and set up the most adequate diagnostic and therapeutic approach 6.
• Endoscopy plays a major role in both diagnosis and treatment of acute GI bleeding, with several hemostasis techniques available during the diagnostic session 6.
• Imaging diagnostic techniques, such as CT angiography and arteriography, may be necessary in challenging cases where medical and endoscopic techniques have failed 6.