Snap Shot A 65-year-old man with a history of alcoholism, tobacco use, and hypertension presents to the general surgery clinic where he was referred for further evaluation of blood in his stool. He reports occasional abdominal pain relieved transiently with meals, and one episode of painful vomiting. Recently, his stools have been black. Spider angiomas, but no palmar erythema or hepatosplenomegaly are observed on exam. Introduction Pathologic bleeding in the upper gastrointestinal tract (esophagus to duodenum) upper GI is considered proximal to ligament of Treitz lower GI is considered distal to ligament of Treitz Characterized by hematemesis and melena (vs. hematochezia as seen in lower GI bleeds) GI bleeding may not always been an immediately apparent source of patient symptoms Etiologies range widely and can include peptic ulcer disease (most common) erosive gastritis esophageal varices Mallory-Weis tear gastric cancer vascular anomalies esophagitis aortoenteric fistulae Risk factors include ETOH abuse tobacco use liver disease repeated NSAID use chronic vomiting h/o PUD Factors associated with increased mortality, recurrent bleeding, and need for endoscopic intervention advanced age > 60 years severe comorbidity active bleeding witnessed hematemesis, red blood per NG tube, bright red blood per rectum hypotension RBC transfusion > 6 units inpatient status at time of bleed severe coagulopathy Presentation Symptoms hematemesis (bloody vomiting) coffee ground appearance melena (dark stools) secondary to metabolized RBCs passing into lower GI tract rarely hematochezia (more common in lower GI bleeds) some cases may not present with observable bleeding patients may initially present with vital sign instability tachycardia/hypotension malaise/weakness fever dizziness Physical exam positive stool guiaic hypotension tachycardia fever Evaluation CBC recall that hematocrit is not an accurate measure of blood loss may be used to monitor treatment (i.e. effectiveness of transfusions) NG tube / NG lavage may be used to sample gastric contents to assess for gastric bleeding Endoscopy may identify specific anatomic source of bleeding, and can facilitate banding procedures Differential Lower GI bleeding All causes of GI bleeding Treatment Medical managament stabilize the patient/vitals (airway, breathing, circulation) intubation may be indicated to protect the airway IV fluid resuscitation for hypotension blood transfusions to raise hematocrit / hemodynamic instability treat underlying condition PPIs for PUD octreotide for varices Surgical intervention endoscopic banding/sclerotherapy indicated for varices open surgical procedure rarely required, indicated only in severe bleeds Transjugular intrahepatic portasystemic shunt (TIPS) consider in patients with recurrent variceal bleeding (1st two bleeding episodes should be managed endoscopically and TIPS should be considered on 3rd episode) Prognosis, Prevention, and Complications Prognosis mortality rate 12-25% in individuals > 60 years of age, 10.1% for those aged 41-50 years, and 3.3% for patients aged 21-31 years patients presenting in hemorrhagic shock have mortality rate of ~30% Prevention treat underlying risk factors Complications chronic anemia, death