Large Intestine: GI Bleeding

Definitions

Location

  • Classic Definitions:
    • Upper GI Bleed (UGIB) – Bleeding Proximal to the Ligament of Treitz
    • Lower GI Bleed (LGIB) – Bleeding Distal to the Ligament of Treitz
  • Newer Definitions:
    • Upper GI Bleed (UGIB) – Bleeding Proximal to the Ligament of Treitz
    • Middle GI Bleed (MGIB) – Bleeding Between the Ligament of Treitz & the Ileocecal Valve
    • Lower GI Bleed (LGIB) – Bleeding Distal to the Ileocecal Valve
  • Obscure GI Bleeding (OGIB) – Bleeding of an Unknown Source After a Negative Initial Evaluation

Presentation

  • Overt Bleeding – Bleeding is Visible to the Physician or Patient
  • Occult Bleeding – Bleeding Not Visible to the Physician or Patient

Overt Bleeding

  • Hematemesis – Blood in Vomitus
  • Hematochezia – Bright Red Blood in Stool
    • Blood Has Not Yet Digested & Indicates a More Distal Source
  • Melena – Dark Black-Tarry Blood in Stool
    • Blood Has Been Partially Digested & Indicates a More Proximal Source

GI Bleeding Work-Up

Initial Orders

  • Thorough History & Physical Exam
  • Nasogastric Tube Lavage (Detects Upper GI Bleeding)
  • Anoscopy/Proctoscopy (Evaluates Distal Lower GI Bleeding)

Next Step

  • Upper GI Bleed: EGD
  • Lower GI Bleed: Colonoscopy
    • Timing: ≤ 24 Hours After Adequate Bowel Prep (Yield Clear-Liquid Stools)
    • If Nondiagnostic: RBC Tagged Scan (Most Sensitive Test)
  • Massive: Angiography

Still Unable to Localize

  • Stable: Angiography & Embolization
    • Consider Capsule Endoscopy if Bleeding Chronic
  • Unstable: Total Colectomy & End Ileostomy

Possible Sources

Stomach

  • Angiodysplasia
  • Dieulafoy Lesion
  • Peptic Ulcer
  • Inflammatory Bowel Disease
  • Malignancy
  • Recent Surgery

Small Intestine

  • Angiodysplasia
  • Dieulafoy Lesion
  • Meckel’s Diverticulum
  • Intussusception
  • Inflammatory Bowel Disease
  • Radiation Enteritis
  • Mesenteric Ischemia
  • Aortoenteric Fistula
  • Malignancy
  • Recent Surgery

Large Intestine (85% of LGIB Originate in the Colon)

  • Angiodysplasia – Most Common Cause of Obscure GI Bleeding
  • Dieulafoy Lesion
  • Stercoral Ulcer
  • Diverticulosis – Most Common Cause of GI Bleed
  • Inflammatory Bowel Disease
  • Radiation Enteritis
  • Infectious Colitis
  • Ischemic Colitis
  • Malignancy
  • Recent Colonoscopy or Biopsy
  • Recent Surgery

Rectum/Anus

  • Angiodysplasia
  • Dieulafoy Lesion
  • Inflammatory Bowel Disease
  • Radiation Proctitis
  • Hemorrhoids
  • Anal Fissure
  • Anorectal Varices
  • Local Trauma
  • Malignancy
  • Recent Surgery