Chapter 17: Gastrointestinal Bleeding

OVERVIEW

Acute gastrointestinal (GI) bleeding is a common problem causing significant morbidity and mortality. The source of GI bleeding can be anywhere in the GI tract, from the esophagus to the rectum. GI bleeding is classified into upper or lower bleeding based on the site of bleeding relative to the ligament of Treitz. Upper GI hemorrhage occurs from sites proximal to the ligament of Treitz and accounts for more than 80% of acute bleeding.¹ Lower GI bleeding originates distal to the ligament of Treitz, most commonly from the colon. The small intestine is the site of bleeding in less than 5% of patients.¹ Hemorrhage persisting or recurring after negative endoscopy is termed obscure bleeding. Occasionally patients present with occult bleeding, where there are no signs of overt bleeding but only symptoms of chronic blood loss anemia. In all cases, thorough investigation to localize the source of bleeding allows rapid and often definitive management.

Incidence and Economic Impact of GI Bleeding

Acute GI hemorrhage is one of the most common problems prompting outpatient, emergency room (ER), and inpatient visits. In 2012, nearly 800,000 patients seen in the emergency department (ED) were discharged with a diagnosis of GI hemorrhage, or 254 visits per 100,000 adults.² Of those patients, 54.6% were admitted, and over 500,000 patients had GI bleeding as their principal diagnosis for admission in 2012, with an estimated cost of nearly $5 billion US. The incidence of acute upper GI bleeding is estimated at 170 cases per 100,000 adults, and increases with age, affecting 1% of those older than age 85, and is more frequent than lower GI bleeding.^3-6 There are geographical variations in the GI bleeding incidence, with reported rates varying from 45 per 100,000 in the Netherlands to 172 per 100,000 in Scotland. This difference is likely related to differences in population demographics and prevalence of various etiological factors between the countries.^7-11

Morbidity and Mortality

Despite advances in therapy, mortality from GI bleeding remains high. In hospital death from GI bleeding in 2012 occurred in 2.2% of cases, and is particularly high in the elderly.² Mortality from GI bleeding occurs frequently on presentation in the ED or early in hospitalization. Evidence suggests that upper GI bleed mortality rates have declined in the last 3 decades, with mortality rates based on the NHDS trending from 4.8% in 1979 to 1989 to 3.1% from 2000 to 2009, primarily due to reductions in early hospital mortality. ^{5-6, 9, 12-13}

INITIAL ASSESSMENT AND RESUSCITATION

A structured approach is recommended in the initial evaluation and management of the patient with acute GI bleeding (Fig. 17-1). Early resuscitation with the aim of restoring hemodynamic stability is the initial priority, followed by a careful history and physical examination to help identify the ...