INTRODUCTION

Gastrointestinal (GI) bleeding accounts for 5% of admissions from the emergency department (ED). An intervention is required to stop ongoing hemorrhage in 10% of

patients. Bleeding can occur anywhere along the GI tract

and can be grossly divided into upper and lower sources.

Upper GI bleeding is defined as occurring proximal to the

ligament of Treitz (the suspensory ligament of the duodenum). Lower GI bleeding is defined as occurring distal to

the ligament of Treitz. Upper GI bleeding is 4-8 times

more common than lower GI bleeding.

It is not always possible to clinically distinguish between

upper and lower GI bleeding in the ED, but appearance of

the gastric contents and stool can provide clues to the source

of the hemorrhage. Hematemesis is the vomiting of blood

and indicates an upper GI bleed. "Coffee ground" emesis

suggests that the blood has partially digested and that bleeding is either slow or has stopped. A nasogastric (NG) tube

aspirate positive for blood also indicates an upper GI source

of bleeding. NG lavage can be negative in 25% of patients

with an upper GI source of bleeding because the nasogastric

tube does not reliably pass the pylorus.

Melena is black, tarry stool that reflects the presence

of blood in the GI tract for more than 8 hours. At least

• Octreotide should be administered in patients with

liver disease and significant upper Gl bleeding, even

when the diagnosis of esophageal varices has not been

confirmed.

• Emergent endoscopy should be arranged when active

upper Gl bleeding is present.

300 mL of blood must be present to produce melena.

Melena is 4 times more likely to be from an upper GI

source of bleeding and almost always reflects bleeding

proximal to the right side of the colon. Hematochezia is

bright red or maroon-colored blood per rectum. It is 6

times more likely to be from a lower GI source. An exception is a rapid upper GI source of bleeding. Hematochezia

is present in 1 0% of upper GI bleeds.

The three most common causes of upper GI bleeding

are peptic ulcer disease, gastritis, and varices ( Table 30-1).

Lower GI bleeding may be due to multiple causes, but

Table 30-1. Causes of upper Gl bleeding.

Cause

Peptic ulcer (duodenal 2/3)

Erosive gastritis

varices (esophageal and gastric)

Mallory-Weiss tear

Other (epistaxis, aortoenteric fistula, carcinoma,

caustic ingestion)

Percentage

40%

25%

20%

5%

1 0%

1 28

GASTROI NTESTINAL BLEEDING

Table 30-2. Causes of lower Gl bleeding.

Cause

Diverticulosis

Inflammatory bowel disease

Hemorrhoids, anal fissure

Neoplasia

Coagulopathy

Arteriovenous malformation

Percentage

60%

1 3%

11%

9%

4%

3%