Gastro-intestinal Haemorrhage

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Referral

Definition

Gastrointestinal (GI) haemorrhage refers to bleeding anywhere along the gastrointestinal tract, which can be classified as upper GI bleeding (proximal to the ligament of Treitz) or lower GI bleeding (distal to the ligament of Treitz).

Aetiology

Upper GI bleeding:

  • Peptic ulcer disease: this is the most common cause, associated with NSAIDs and H. pylori infection.
  • Oesophageal varices: caused by portal hypertension in liver disease.
  • Mallory-Weiss tear: mucosal tear due to forceful vomiting.
  • Gastro-oesophageal reflux disease (GORD): can cause erosive oesophagitis.
  • Gastric cancer: which can present with chronic occult bleeding.

Lower GI bleeding:

  • Diverticular disease: the most common cause in older adults.
  • Colorectal cancer: this can present with chronic occult bleeding.
  • Haemorrhoids/piles: a common cause of bright red rectal bleeding.
  • Inflammatory bowel disease (IBD): bleeding in Crohn’s disease and ulcerative colitis.
  • Angiodysplasia: a vascular malformations in elderly patients.

Pathophysiology

  • Haemorrhage results from mucosal injury, vascular malformations, or increased portal pressure.
  • Bleeding can present as overt (visible blood loss) or occult (hidden blood loss leading to anaemia).
  • Severe haemorrhage can lead to hypovolaemia and haemodynamic instability.

Risk factors

  • NSAID or aspirin use.
  • Alcohol-related liver disease (risk of varices).
  • H. pylori infection.
  • Anticoagulant or antiplatelet therapy.
  • Inflammatory bowel disease.
  • Smoking.

Signs and symptoms

Upper GI bleeding:

  • Haematemesis: vomiting of fresh red blood or coffee-ground material.
  • Melaena: black, tarry stools due to digested blood.
  • Epigastric pain: this suggests peptic ulcer disease.

Lower GI bleeding:

  • Haematochezia: bright red or maroon blood per rectum.
  • Abdominal pain: this would suggests IBD or diverticulitis.
  • Iron-deficiency anaemia: this would suggests chronic blood loss.

Investigations

  • Blood tests:
    • Full blood count: anaemia (low haemoglobin), thrombocytopenia.
    • Clotting screen: prolonged INR in liver disease.
    • Urea and electrolytes: raised urea in upper GI bleeding.
    • Cross-match blood: if transfusion is needed.
  • Endoscopy (gold standard for upper GI bleeding): it identifies bleeding source and allows therapeutic intervention.
  • CT angiography: performed to check for active lower GI bleeding.
  • Colonoscopy: first-line for patients with lower GI bleeding if they are haemodynamically stable.

Management

1. Initial Resuscitation:

  • ABCDE approach: check airway, breathing, and circulation.
  • IV fluids (hospital): if haemodynamically unstable.
  • Blood transfusion: if low haemoglobin (hb).
  • Proton pump inhibitors (PPIs): can be prescribed for suspected peptic ulcer bleeding.
  • Correct clotting abnormalities (secondary care): vitamin K or fresh frozen plasma if needed.

2. Specific Management Based on Cause:

  • Peptic ulcer disease: an endoscopic therapy (e.g., injection, coagulation, or clipping).
  • Oesophageal varices: band ligation or sclerotherapy.
  • Diverticular bleeding: depending on severity - conservative management, but embolisation or surgery if persistent.
  • Haemorrhoidal bleeding: conservative measures, banding, or haemorrhoidectomy.

3. Surgery and Interventional Radiology:

  • Emergency surgery: performed in cases of perforated ulcers or severe ongoing bleeding.
  • Embolisation: this is considered for uncontrolled lower GI bleeding.

Referral

  • Urgent gastroenterology referral: if you suspect upper GI bleeding.
  • Colorectal surgery referral: for lower GI bleeding requiring intervention.
  • A/E referral: if haemodynamic instability persists.
GastroenterologymypanotesGastro-intestinal Haemorrhage