###Basics

- UGIB has a source *proximal* to ligament of Treitz, LGIB is distal

- First priority is to ensure pt is **hemodynamically stable!**
- Remember you have to r/o serious causes before you can attribute bleeding to a
benign cause like hemorrhoids!
###DDx LGIB
- Colon Ca
- Colitis
- IBD (UC >> Crohn's)
- Bacterial
- Radiation
- Diverticulosis
- Angiodysplasia
- Brisk UGIB
- Anorectal causes
- Hemorrhoids
- Anal fissure
- Rectal ulcer
###DDx UGIB
- PUD
- H. pylori (50%)
- NSAIDs
- Gastric hypersecrtion (e.g. Zollinger-Ellison)
- Varices
- Esophageal gastric
- Gastritis/Gastropathy/duodenitis
- Erosive esophagitis/ulcer
- e.g. due to GERD
- Mallory-Weiss tear
- Vascular lesions
- Dieulafoy's lesion (gives sudden massive UGIB)
###Hx
- UGIB-predominant Sx:
- N&V: Hematemesis, coffee-ground emesis
- Melena
- Epigastric pain
- Vasovagal
- LGIB-predominant Sx:
- Diarrhea
- Tenesmus
- BRBPR
- Hematochezia
- Things wh/ can mimic stool changes:
- Beet ingestion
- Iron supplementation
- Pepto-Bismol
- Questions about bleeding:
- Orthostatic hypotension Sx?
- Amount of blood?
- Blood just on TP? Mixed in w/ stool?
- BM questions: changes in calibre, mucous
- Recent C-scope or EGD? Recent radiation?
- FHx of Colon Ca?
- Coagulopathy issues:
- NSAID use?
- Use of anticoagulants?
- Use of ASA? Clopidogrel?
- EtOH use?
- Known coagulopathies?
###PEx
- Vitals! Esp HR & BP
- w/ **orthostatics!**
- JVP
- Abdo exam, incl:
- Ascites?
- HSM? (may imply portal HTN)
- Other signs of liver failure?
- Anorectal exam
- FOBT testing (esp if any mimic factors found on Hx)
###High-Risk Pts for GI Bleed
- Make sure to add a PPI for cytoprotection in these pts:
- Previous GI Bleed
- ICU admission
- Prolonged NSAID use
- Sig EtOH use (Previous EGD? Varices?)
###Investigations
- CBC (for Hb, Hct, plt)
- PT, PTT/INR
- Liver enzymes
- BUN, Cr
- BUN/Cr ratio is >36 in UGIB b/c GI resorbs the blood)
- Consider EGD and/or C-scope
- For unstable/recurrent GI bleed:
- Arteriography
- Tagged RBC scan
###Management
- Initial Rx:
- Fluid resusc
- Transfuse (consider if >2L fluid needed)
- Reverse coagulopathyies: FFP & vit K, Octiplex
- For varices: octreotide 50 mcg IV bolus + 50 mcg/hr infusion
- Can also try EGD band ligation
- For PUD: PPI infusion if needed (e.g. Omeprazole 80 mg IV bolus, then 8 mg/h i
nfusion)
- For pts on ASA for CV risk, D/C ASA until 7d after bleed
- Mallory-Weiss: usually stops spontaneously
- Esophagitis/Gastritis: PPI
- Diverticulosis and Angiodysplasia usually stop spontanteously, but can be trea
ted endoscopically if needed