Upper GI bleed occurs proximal to the ligament of Treitz, while lower GI bleed occurs distal to it. Acute upper GI bleeding causes hematemesis or melena, while lower GI bleeding presents as hematochezia. In the ER, management of acute GI bleeding involves stabilizing ABCs, administering IV fluids and blood products, and performing tests like CBC, INR, and UGI endoscopy once stabilized. Later management may include identifying the bleeding source, treating with drugs like PPIs or vasopressors, or pursuing interventions like TIPS or surgery if bleeding persists. Obscure GI bleeding has no identified source on initial endoscopy and workup may involve repeated endoscopy, capsule end

1. GI bleed
Upper GI- proximal to ligament of Treitz
&
Lower GI- distal to ligament of Treitz

2. Acute UGI bleeding
Causes hematemesis or malena
Hematochezia- rare

3. Etiology
 Peptic ulcer disease- commonest
 Varices- esophageal, rarely gastric
 Mallory-Weiss tear at GE junction
 Erosive gastritis- stress, alcohol,
NSAIDs
 Rare-
 Vascular ectasias
 Cancer
 Erosive esophagitis

4. Management- in ER
 A.B.C.
 Hypotension & tachycardia suggest
severity of bleed, not hematocrit
 Two large bore IV canulas for fluid &
blood replacement
 Check CBC, INR, Cr, SGPT, blood
group
 NG tube to confirm & quantitate bleed
 PRBC, FFP, PRP transfusion; as

5. Management- later
 H & PE suggesting possible cause- PUD, CLD, drugs
 UGIE- once patient stabilized, sooner the better,
helps-
 Identify source
 Determine risk of rebleed
 Render endoscopic therapy
 Drugs-
 PPI- IV or oral- for PUD
 Octreotide/Terlipressin- CIVI- for variceal bleed
 Other Rx-
 TIPS
 Intra-arterial embolization

6. Surgery
If all else fails

7. Acute LGI bleed
 Commonly from colon- ~85%,
only ~5% from small intestine
 Mild anorectal bleed to
frank hematochezia
 Mixed with stool?
 Less serious, more benign
 Spontaneously subsides in ~85%

8. Etiology
 Young-
 Infectious colitis
 Anorectal disease
 IBD
 Older-
 Diverticulosis- commonest cause of major LGI bleed
 Vascular ectasia
 Polyps or Malignancy
 Ischemia

9. Management- in ER
Hemodynamic assessment- PR & BP
Labs- CBC, INR, Cr, SGPT
IVF & blood products

10. Evaluation- later
 UGIE- to rule out UGI source of bleed
 Proctoscopy/sigmoidoscopy
 Localize proximal colonic bleed
 Colonoscopy
 Nuclear bleeding scan- 0.1 ml/min
 Selective angiography- 0.5 ml/min
 Push enteroscopy/capsule imaging-
to detect SI bleeding

11. Treatment
 Therapeutic colonoscopy-
 Epinephrine injection, cautery, clipping
 Intra-arterial vasopressin/embolization-
 For poor surgical candidates
 Surgery- significant blood loss- 4-6 units
over 24 hours or >10 units BT
 Localized lesion- limited resection
 Not localized lesion- extensive resection
 Recurrent bleeding

12. Occult GI bleed
 Not apparent to the patient
 Identified as +ve FOBT/FIT or
iron-deficiency anemia
 Causes-
 Malignancy, vascular ectasias, PUD, erosions
 Infection- hookworm, TB
 Drugs- aspirin, NSAIDs
 Ix- UGIE ± colonoscopy
 Rx- iron replacement ± transfusion while
evaluatingRx of cause detected, if any

13. Obscure GI bleed
 No source identified despite UGIE & colonoscopy
 Overt or Occult
 Evaluation- depends on age & symptoms;
aggressive in younger or symptomatic patients
 Ix-
 Repeat UGIE + colonoscopy
 Capsule endoscopy
 Angiography
 CT scan
 Laparotomy