Approach to

Gastrointestinal
Bleeding

Contents:
Differentiation of Upper and Lower GIB
Differentiation of Acute and Chronic GIB
Resuscitation Requirement Assessment
Diagnostic Approach to Upper GIB
Diagnostic Approach to Lower GIB
GIB of Obscure Origin
Occult Fecal Blood Test

Differentiation of Upper and Lower

GIB
Upper GIB
Presentation:
- Hematemesis
- Melena
- Hematochezia
Hyperactive bowel
sound
Elevated BUN
Bloody nasogastric

Lower GIB
Presentation:
- Hematochezia
- Melena
-

Differentiation of Acute and Chronic

GIB
Acute GIB
Postural changes in BP /
HR tachycardia
recumbent hypotension
Hemoglobin level
normal / slight decrease
Normocytic
normochromic anemia

Chronic GIB
Normal HR / BP

Marked decrease in
haemoglobin level
Mycrocytic Hypochromic
Anemia (low MCV)

Assessment for Resuscitation

Clinical Feature of Hypovolemic Shock
Early
Advanced
HR > 100/min
SBP < 100 mmHg OR
Decrease 40 mmHg than
baseline BP
CRT > 2s
Narrow pulse pressure
Postural Hypotension
Pale, sweaty, cold, agitated

RR > 20/min
Cold mottled periphery
Low GCS

Assessment for Resuscitation (cont.)

Resuscitation in Acute Hemorrhage
A + - Check Airway (especially in low GCS /
B
continue vomiting)
- Intubate / Give 02 if needed
- Get help
- Monitor
C
- Secure access
- Resuscitation and reassessment

Assessment for Resuscitation (cont.)

Circulation
- BP, RR, GCS, peripheral perfusion every 15
Monitor
min
- Urgent CBC, U&E, LFT, Coagulation
Screening and Cross match
- Urine output (insert Foleys Catheter)
- 2 large bore cannulae in antecubital
Secure
Access
veins (or equivalent) OR
- Central venous cannulation in case
difficult peripheral venous access

Assessment for Resuscitation (cont.)

Circulation
Early

Advance

Resuscitat 0.5 1 L crystalloid / colloid 1 2 L IV crystalloid / colloid

ion
2 units red cell (Hb < 8 g/dL Red cells as soon as
OR ongoing bleeding OR > 2
available (O- preferable)
L IV crystalloid given)
Reassess
ment

1. Any advance shock criteria

2. Discuss with haematologist
when:
-. With coagulopathy/ on
anticoagulant
-. INR > 1.4
-. Platelet < 100 x 109 / L
-. Fibrinogen < 1 g/L
-. > 4 L IV fluid (any form)
administered

1. Any advance shock criteria

2. If ongoing advance shock
consult specialist

Diagnostic Approach to Upper GIB

Diagnostic Approach to Upper GIB

(cont.)

Diagnostic Approach to
Lower GIB

GIB of Obscure Origin

Definition:
Persistent / recurrent bleeding
With no identifiable source by routine endoscopy /
contrast X-ray
May be overt (melena/ BPR) or occult (Iron deficiency
anemia)

GIB of Obscure Origin (cont.)

Approach:
Angiography massive obscure bleeding
Video Capsule enteroscopy
if positive: manage accordingly
if negative: observe (OR)
further test (in alarming situation)
Push enteroscopy

GIB of Obscure Origin (cont.)

Approach: (cont.)
Newer endoscopic technique: Double balloon / single
balloon / spiral enteroscopy
Newer imaging technique: CT / MR enterography
Other test:

99m

Tc-labelled RBC scintigraph (reveal vascular anomalies)

99m

Tc-pertechnetate scintigraph (Meckels Diverticulum)

GIB of Obscure Origin (cont.)

Approach: (cont.)
All else fails
+
In severe recurring / persistent bleeding requiring
repeated transfusion
Intraoperative Endoscopy

Occult Fecal Blood Test

Recommended:
Colorectal cancer screening
Average risk adult (early 50 y/o)
Adult with 1st-degree relative with colorectal neoplasm
at > 60 y/o
Adult with two 2nd-degree relatives with colorectal
cancer at > 40 y/o
Positive test colonoscopy negative colonoscopy: no
further work up (unless patient have iron deficiency