Gastrointestinal Bleeding

Clinical Presentation

The clinical presentation of patients with gastrointestinal bleeding typically reflects the site, etiology, and rate of bleeding. Gastrointestinal tract bleeding is manifest in one or more ways. Hematemesis, melena, or hematochezia are the most common manifestations of gastrointestinal bleeding. Hematemesis is defined as vomiting of blood and is caused by upper gastrointestinal bleeding from the esophagus, stomach, or proximal small bowel. Blood may be bright red or it may be old and take on

Initial Patient Assessment

When a patient is found to have one of the previously mentioned manifestations of gastrointestinal bleeding, the first step in management should be to assess the severity of bleeding. Assessment of the patient's hemodynamics should be emphasized (Table 1). This hemodynamic assessment forms the basis for further management. Ongoing assessment of the vital signs further focuses resuscitation efforts, and also provides important prognostic information. Finally, ongoing and careful assessment of

Resuscitation

The more severe the bleeding (ie, unstable vital signs and evidence of ongoing bleeding), the more vigorous the resuscitation efforts should be. In patients who have any evidence of hemodynamic instability, two large-bore intravenous catheters should be placed immediately. Colloid (normal saline or lactated Ringer's solution) should be infused as rapidly as the patient's cardiovascular system allows to restore the vital signs toward normal. ICU monitoring is indicated in hemodynamically

History, Symptoms, and Signs

Once the patient's hemodynamics and overall condition has been assessed and stabilized, attention should turn to the clinical history. The history helps the clinician assess the severity of bleeding and make a preliminary assessment of the site and cause. Historical features important in assessing the etiology of gastrointestinal bleeding are shown in Box 1.

Simple demographic characteristics are an essential part of the history. For example, elderly patients may bleed from a number of diseases

Laboratory Evaluation

Unfortunately, far too great a focus has been historically placed on the hematocrit value in patients with gastrointestinal bleeding. This is because the hematocrit, when determined soon after the onset of bleeding, may not reflect blood loss accurately. For example, the hematocrit during exsanguination may not be substantially depressed until extravascular fluid and subsequent hemodilution take place. A single hematocrit level may not reflect the degree of bleeding. The hematocrit value only

Clinical Localization of Bleeding

The localization of bleeding should begin with the history and physical examination and should be focused immediately, during hemodynamic stabilization. Hematemesis denotes an upper gastrointestinal source of bleeding. Melena indicates that blood has been in the gastrointestinal tract for extended periods of time and is usually the result of upper gastrointestinal bleeding, but its source may be the distal small bowel or even the ascending colon. In the latter instance, the volume of bleeding

Diagnosis and Therapy

Diagnostic tests play a central role in the evaluation of patients with gastrointestinal bleeding. The major categories of tests available include the following: (1) endoscopy; (2) barium radiographs; (3) radionuclide imaging; (4) angiography; and (5) miscellaneous tests (ie, abdominal CT scanning). The radiographic tests allow diagnosis only, whereas endoscopic tests allow both diagnosis and therapy. The importance of endoscopic therapy is emphasized by studies performed before the advent of