{{Short description|Bleeding in the gastrointestinal tract}} {{Infobox medical condition (new) | name = Gastrointestinal bleeding | synonyms = Gastrointestinal hemorrhage, GI bleed | image = MALT 4.jpg | caption = Endoscopic image of gastric MALT lymphoma taken in antrum of stomach in patient who presented with upper GI hemorrhage. Appearance is similar to gastric ulcer with adherent blood clot. Pathology was consistent with gastric lymphoma. | symptoms = Vomiting red blood, vomiting black blood, bloody stool, black stool, fatigue<ref name=Kim2014/> | complications = Iron-deficiency anemia, heart-related chest pain<ref name=Kim2014/> | onset = | duration = | types = Upper gastrointestinal bleeding, lower gastrointestinal bleeding<ref name=EBMED2004/> | causes = '''Upper''': peptic ulcer disease, esophageal varices due to liver cirrhosis, cancer<ref name=Epi2008/><br />'''Lower''': hemorrhoids, cancer, inflammatory bowel disease<ref name=EBMED2004/> | risks = | diagnosis = Medical history and physical examination, blood tests<ref name=Kim2014/> | differential = | prevention = | treatment = Intravenous fluids, blood transfusions, endoscopy<ref name=Overall2011/><ref name=Chavez2011/> | medication = Proton pump inhibitors, octreotide, antibiotics<ref name=Chavez2011/><ref name=PPI2007/> | prognosis = ~15% risk of death<ref name=Kim2014/><ref name=Wang2013/> | frequency = '''Upper''': 100 per 100,000 adults per year<ref name=Red2010/><br />'''Lower''': 25 per 100,000 per year<ref name=EBMED2004/> | deaths = }} <!-- Definition and symptoms --> '''Gastrointestinal bleeding''' ('''GI bleed'''), also called '''gastrointestinal hemorrhage''' ('''GIB'''), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum.<ref name=NIH2014>{{cite web|title=Bleeding in the Digestive Tract|url=http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/bleeding-in-the-digestive-tract/Pages/facts.aspx|website=The National Institute of Diabetes and Digestive and Kidney Diseases|access-date=6 March 2015|date=September 17, 2014|archive-url=https://web.archive.org/web/20150221091014/http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/bleeding-in-the-digestive-tract/Pages/facts.aspx|archive-date=21 February 2015}}</ref> When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool.<ref name=Kim2014/> Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain.<ref name=Kim2014/> Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out.<ref name=Kim2014/><ref name=NIH2014/> Sometimes in those with small amounts of bleeding no symptoms may be present.<ref name=Kim2014>{{cite journal|last1=Kim|first1=BS|last2=Li|first2=BT|last3=Engel|first3=A|last4=Samra|first4=JS|last5=Clarke|first5=S|last6=Norton|first6=ID|last7=Li|first7=AE|title=Diagnosis of gastrointestinal bleeding: A practical guide for clinicians.|journal=World Journal of Gastrointestinal Pathophysiology|date=15 November 2014|volume=5|issue=4|pages=467–78|pmid=25400991|doi=10.4291/wjgp.v5.i4.467|pmc=4231512 |doi-access=free }}</ref>
<!-- Causes and diagnosis --> Bleeding is typically divided into two main types: upper gastrointestinal bleeding and lower gastrointestinal bleeding.<ref name=EBMED2004>{{cite journal|last=Westhoff|first=John|title=Gastrointestinal Bleeding: An Evidence-Based ED Approach To Risk Stratification|journal=Emergency Medicine Practice|date=March 2004|volume=6|issue=3|url=http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=75|archive-url=https://web.archive.org/web/20130722192754/http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=75|archive-date=2013-07-22|access-date=2012-04-20}}</ref> Causes of upper GI bleeds include: peptic ulcer disease, esophageal varices due to liver cirrhosis and cancer, among others.<ref name=Epi2008>{{cite journal|last=van Leerdam|first=ME|title=Epidemiology of acute upper gastrointestinal bleeding.|journal=Best Practice & Research. Clinical Gastroenterology|year=2008|volume=22|issue=2|pages=209–24|pmid=18346679|doi=10.1016/j.bpg.2007.10.011}}</ref> Causes of lower GI bleeds include: hemorrhoids, cancer, and inflammatory bowel disease among others.<ref name=EBMED2004/><ref name=Kim2014/> Small amounts of bleeding may be detected by fecal occult blood test.<ref name=Kim2014/> Endoscopy of the lower and upper gastrointestinal tract may locate the area of bleeding.<ref name=Kim2014/> Medical imaging may be useful in cases that are not clear.<ref name=Kim2014/> Bleeding may also be diagnosed and treated during minimally invasive angiography procedures such as hemorrhoidal artery embolization.<ref>{{Cite AV media |url=https://www.youtube.com/watch?v=Whje31Jlm10&t=109s |title=Hemorrhoidal Artery Embolization Minimally Invasive Treatment for Symptomatic Internal Hemorrhoids |date=2024-06-24 |last=UCLA Health |access-date=2024-08-16 |via=YouTube}}</ref><ref>{{Cite web |title=Hemorrhoidal Artery Embolization (HAE) |url=https://www.uclahealth.org/medical-services/radiology/interventional-radiology/HAE |access-date=2024-08-16 |website=www.uclahealth.org |language=en}}</ref>
<!-- Treatment --> Initial treatment focuses on resuscitation which may include intravenous fluids and blood transfusions.<ref name=Overall2011>{{cite journal|last=Jairath|first=V|author2=Barkun, AN|title=The overall approach to the management of upper gastrointestinal bleeding|journal=Gastrointestinal Endoscopy Clinics of North America|date=October 2011|volume=21|issue=4|pages=657–70|pmid=21944416|doi=10.1016/j.giec.2011.07.001}}</ref> Often blood transfusions are not recommended unless the hemoglobin is less than 70 or 80 g/L.<ref name=Wang2013>{{cite journal|last1=Wang|first1=J|last2=Bao|first2=YX|last3=Bai|first3=M|last4=Zhang|first4=YG|last5=Xu|first5=WD|last6=Qi|first6=XS|title=Restrictive vs liberal transfusion for upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials.|journal=World Journal of Gastroenterology|date=28 October 2013|volume=19|issue=40|pages=6919–27|pmid=24187470|doi=10.3748/wjg.v19.i40.6919|pmc=3812494|doi-access=free}}</ref><ref name=Sal2014>{{cite journal|last1=Salpeter|first1=SR|last2=Buckley|first2=JS|last3=Chatterjee|first3=S|title=Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review.|journal=The American Journal of Medicine|date=February 2014|volume=127|issue=2|pages=124–131.e3|pmid=24331453|doi=10.1016/j.amjmed.2013.09.017}}</ref> Treatment with proton pump inhibitors, octreotide, and antibiotics may be considered in certain cases.<ref name=Chavez2011>{{cite journal|last=Chavez-Tapia|first=NC|author2=Barrientos-Gutierrez, T |author3=Tellez-Avila, F |author4=Soares-Weiser, K |author5=Mendez-Sanchez, N |author6=Gluud, C |author7=Uribe, M |title=Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review|journal=Alimentary Pharmacology & Therapeutics|date=September 2011|volume=34|issue=5|pages=509–18|pmid=21707680|doi=10.1111/j.1365-2036.2011.04746.x|s2cid=8673988|doi-access=free}}</ref><ref name=PPI2007>{{cite journal|last=Leontiadis|first=GI |author2=Sreedharan, A |author3=Dorward, S |author4=Barton, P |author5=Delaney, B |author6=Howden, CW |author7=Orhewere, M |author8=Gisbert, J |author9=Sharma, VK |author10=Rostom, A |author11=Moayyedi, P |author12=Forman, D|title=Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding|journal=Health Technology Assessment|date=December 2007|volume=11|issue=51|pages=iii–iv, 1–164|pmid=18021578|doi=10.3310/hta11510|doi-access=free }}</ref><ref name=N2010>{{cite journal|last=Cat|first=TB|author2=Liu-DeRyke, X|title=Medical management of variceal hemorrhage|journal=Critical Care Nursing Clinics of North America|date=September 2010|volume=22|issue=3|pages=381–93|pmid=20691388|doi=10.1016/j.ccell.2010.02.004}}</ref> If other measures are not effective, an esophageal balloon may be attempted in those with presumed esophageal varices.<ref name=EBMED2004/> Endoscopy of the esophagus, stomach, and duodenum or endoscopy of the large bowel are generally recommended within 24 hours and may allow treatment as well as diagnosis.<ref name=Overall2011/>
<!-- Epidemiology and prognosis --> An upper GI bleed is more common than lower GI bleed.<ref name=EBMED2004/> An upper GI bleed occurs in 50 to 150 per 100,000 adults per year.<ref name=Red2010>{{cite journal|last=Jairath|first=V|author2=Hearnshaw, S |author3=Brunskill, SJ |author4=Doree, C |author5=Hopewell, S |author6=Hyde, C |author7=Travis, S |author8=Murphy, MF |title=Red cell transfusion for the management of upper gastrointestinal haemorrhage|journal=Cochrane Database of Systematic Reviews|date=2010-09-08|issue=9|article-number=CD006613|pmid=20824851|doi=10.1002/14651858.CD006613.pub3|editor1-last=Jairath|editor1-first=Vipul}}</ref> A lower GI bleed is estimated to occur in 20 to 30 per 100,000 per year.<ref name=EBMED2004/> It results in about 300,000 hospital admissions a year in the United States.<ref name=Kim2014/> Risk of death from a GI bleed is between 5% and 30%.<ref name=Kim2014/><ref name=Wang2013/> Risk of bleeding is more common in males and increases with age.<ref name=EBMED2004/>
==Classification== thumb|Causes of gastrointestinal bleeding Gastrointestinal bleeding can be roughly divided into two clinical syndromes: upper gastrointestinal bleeding and lower gastrointestinal bleeding.<ref name=EBMED2004/> About 2/3 of all GI bleeds are from upper sources and 1/3 from lower sources.<ref name="JAMA2012" /> Common causes of gastrointestinal bleeding include infections, cancers, vascular disorders, adverse effects of medications, and blood clotting disorders.<ref name=EBMED2004/> Obscure gastrointestinal bleeding (OGIB) is when a source is unclear following investigation.<ref>{{cite journal |last1= Tanabe|first1=S |date=November 2016 |title=Diagnosis of Obscure Gastrointestinal Bleeding|journal= Clinical Endoscopy|volume=49 |issue=6 |pages=539–541 |doi=10.5946/ce.2016.004 |pmid= 26879551|pmc=5152785}}</ref>
===Upper gastrointestinal=== {{main|Upper gastrointestinal bleeding}} [[File:DU 2.jpg|thumb|right|Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper gastrointestinal hemorrhage.]] [[Image:Gastric ulcer 2.jpg|right|thumb|Endoscopic image of small gastric ulcer with visible blood vessels, a potential warning sign for upper gastrointestinal bleeding]] Upper gastrointestinal bleeding is from a source between the pharynx and the ligament of Treitz. An upper source is characterised by hematemesis (vomiting up blood) and melena (tarry stool containing altered blood). About half of cases are due to peptic ulcer disease (gastric or duodenal ulcers).<ref name=Epi2008/> Esophageal inflammation and erosive disease are the next most common causes.<ref name=Epi2008/> In those with liver cirrhosis, 50–60% of bleeding is due to esophageal varices.<ref name=Epi2008/> Approximately half of those with peptic ulcers have an ''H. pylori'' infection.<ref name=Epi2008/> Other causes include Mallory-Weiss tears, cancer, and angiodysplasia.<ref name=EBMED2004/>
A number of medications are found to cause upper GI bleeds.<ref name=SIGN2008/> NSAIDs or COX-2 inhibitors increase the risk about fourfold.<ref name=SIGN2008/> SSRIs, corticosteroids, and anticoagulants may also increase the risk.<ref name=SIGN2008/> The risk with dabigatran is 30% greater than that with warfarin.<ref>{{cite journal|last=Coleman|first=CI |author2=Sobieraj, DM |author3=Winkler, S |author4=Cutting, P |author5=Mediouni, M |author6=Alikhanov, S |author7=Kluger, J|title=Effect of pharmacological therapies for stroke prevention on major gastrointestinal bleeding in patients with atrial fibrillation.|journal=International Journal of Clinical Practice|date=January 2012|volume=66|issue=1|pages=53–63|pmid=22093613|doi=10.1111/j.1742-1241.2011.02809.x|s2cid=205877572 |doi-access=free}}</ref>
===Lower gastrointestinal=== {{main|Lower gastrointestinal bleeding}} [[Image:Diverticulosis 2.jpg|thumb|Diverticular disease can potentially cause lower gastrointestinal bleeding]] Lower gastrointestinal bleeding is typically from the colon, rectum or anus.<ref name=EBMED2004/> Common causes of lower gastrointestinal bleeding include hemorrhoids, cancer, angiodysplasia, ulcerative colitis, Crohn's disease, and aortoenteric fistula.<ref name=EBMED2004/> It may be indicated by the passage of fresh red blood rectally, especially in the absence of bloody vomiting. Lower gastrointestinal bleeding could also lead to melena if the bleeding occurs in the small intestine or proximal colon.<ref name=Kim2014/>
==Signs and symptoms== Gastrointestinal bleeding can range from small non-visible amounts, which are only detected by laboratory testing, to massive bleeding where bright red blood is passed and shock develops. Rapid bleeding may cause syncope.<ref name=Pra2013/> The presence of bright red blood in stool, known as hematochezia, typically indicates lower gastrointestinal bleeding. Digested blood from the upper gastrointestinal tract may appear black rather than red, resulting in "coffee ground" vomit or melena.<ref name=EBMED2004/> Other signs and symptoms include feeling tired, dizziness, and pale skin color.<ref name=Pra2013>{{cite journal|last1=Prasad Kerlin|first1=Meeta|last2=Tokar|first2=Jeffrey L.|title=Acute Gastrointestinal Bleeding|journal=Annals of Internal Medicine|date=6 August 2013|volume=159|issue=3|pages=ITC2–1, ITC2–2, ITC2–3, ITC2–4, ITC2–5, ITC2–6, ITC2–7, ITC2–8, ITC2–9, ITC2–10, ITC2–11, ITC2–12, ITC2–13, ITC2–14, ITC2–15; quiz ITC2–16|doi=10.7326/0003-4819-159-3-201308060-01002|pmid=23922080|s2cid=19188697}}</ref>
A number of foods and medications can turn the stool either red or black in the absence of bleeding.<ref name=EBMED2004/> Bismuth found in many antacids may turn stools black as may activated charcoal.<ref name=EBMED2004/> Blood from the vagina or urinary tract may also be confused with blood in the stool.<ref name=EBMED2004/>
==Diagnosis== [[Image:Positive fecal occult blood test.jpg|thumb|A positive fecal occult blood test]] Diagnosis is often based on direct observation of blood in the stool or vomit. Although fecal occult blood testing has been used in an emergency setting, this use is not recommended as the test has only been validated for colon cancer screening.<ref>{{Cite journal|last1=Stasi|first1=Elisa|last2=Michielan|first2=Andrea|last3=Morreale|first3=Gaetano Cristian|last4=Tozzi|first4=Alessandro|last5=Venezia|first5=Ludovica|last6=Bortoluzzi|first6=Francesco|last7=Triossi|first7=Omero|last8=Soncini|first8=Marco|last9=Leandro|first9=Gioacchino|last10=Milazzo|first10=Giuseppe|last11=Anderloni|first11=Andrea|date=2019-03-01|title=Five common errors to avoid in clinical practice: the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) Choosing Wisely Campaign|journal=Internal and Emergency Medicine|volume=14|issue=2|pages=301–308|doi=10.1007/s11739-018-1992-x|pmid=30499071|s2cid=54167009|issn=1970-9366}}</ref> Differentiating between upper and lower bleeding in some cases can be difficult. The severity of an upper GI bleed can be judged based on the Blatchford score<ref name=Overall2011/> or Rockall score.<ref name=SIGN2008/> The Rockall score is the more accurate of the two.<ref name=SIGN2008/> As of 2008 there is no scoring system useful for lower GI bleeds.<ref name=SIGN2008/>
===Clinical=== Gastric aspiration and or lavage, where a tube is inserted into the stomach via the nose in an attempt to determine if there is blood in the stomach, if negative does not rule out an upper GI bleed<ref>{{cite journal|last=Palamidessi|first=N|author2=Sinert, R |author3=Falzon, L |author4=Zehtabchi, S |title=Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis.|journal=Academic Emergency Medicine |date=February 2010|volume=17|issue=2|pages=126–32|pmid=20370741|doi=10.1111/j.1553-2712.2009.00609.x|doi-access=free}}</ref> but if positive is useful for ruling one in.<ref name=JAMA2012>{{cite journal |vauthors=Srygley FD, Gerardo CJ, Tran T, Fisher DA |title=Does this patient have a severe upper gastrointestinal bleed? |journal=JAMA |volume=307 |issue=10 |pages=1072–9 |date=March 2012 |pmid=22416103 |doi=10.1001/jama.2012.253 }}</ref> Clots in the stool indicate a lower GI source while melana stools an upper one.<ref name=JAMA2012/>
===Laboratory testing=== Recommended laboratory blood testing includes: cross-matching blood, hemoglobin, hematocrit, platelets, coagulation time, and electrolytes.<ref name=Overall2011/> If the ratio of blood urea nitrogen to creatinine is greater than 30 the source is more likely from the upper GI tract.<ref name=JAMA2012/>
===Imaging=== A CT angiography is useful for determining the exact location of the bleeding within the gastrointestinal tract.<ref>{{cite journal|last=Wu|first=LM |author2=Xu, JR |author3=Yin, Y |author4=Qu, XH|title=Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis.|journal=World Journal of Gastroenterology|date=2010-08-21|volume=16|issue=31|pages=3957–63|pmid=20712058|pmc=2923771|doi=10.3748/wjg.v16.i31.3957 |doi-access=free }}</ref> Nuclear scintigraphy is a sensitive test for detecting occult gastrointestinal bleeding when direct imaging with upper and lower endoscopies are negative. Direct angiography allows for embolization of a bleeding source, but requires a bleeding rate faster than 1mL/minute.<ref name=IC2010/>
==Prevention== In patients with significant varices or cirrhosis nonselective β-blockers reduce the risk of future bleeding.<ref name=N2010/> With a target heart rate of 55 beats per minute B-blockers reduce the absolute risk of bleeding by 10%.<ref name=N2010/> Endoscopic band ligation (EBL) is also effective at improving outcomes.<ref name=N2010/> Either B-blockers or EBL is recommended as initial preventative measures.<ref name=N2010/> In patients who have had a previous variceal bleed both treatments are recommended.<ref name=N2010/> Some evidence supports the addition of isosorbide mononitrate.<ref>{{cite journal|last=Li|first=L|author2=Yu, C |author3=Li, Y |title=Endoscopic band ligation versus pharmacological therapy for variceal bleeding in cirrhosis: a meta-analysis|journal=Canadian Journal of Gastroenterology|date=March 2011|volume=25|issue=3|pages=147–55|pmid=21499579|pmc=3076033|doi=10.1155/2011/346705|doi-access=free}}</ref> Testing for and treating those who are positive for ''H. pylori'' is recommended.<ref name=SIGN2008/> Transjugular intrahepatic portosystemic shunting (TIPS) may be used to prevent bleeding in people who re-bleed despite other measures.<ref name=SIGN2008/>
Among patients admitted to the ICU with high risk of bleeding, a PPI or H2RA appears useful.<ref>{{cite journal |last1=Ye |first1=Zhikang |last2=Reintam Blaser |first2=Annika |last3=Lytvyn |first3=Lyubov |last4=Wang |first4=Ying |last5=Guyatt |first5=Gordon H |last6=Mikita |first6=J Stephen |last7=Roberts |first7=Jamie |last8=Agoritsas |first8=Thomas |last9=Bertschy |first9=Sonja |last10=Boroli |first10=Filippo |last11=Camsooksai |first11=Julie |last12=Du |first12=Bin |last13=Heen |first13=Anja Fog |last14=Lu |first14=Jianyou |last15=Mella |first15=José M |last16=Vandvik |first16=Per Olav |last17=Wise |first17=Robert |last18=Zheng |first18=Yue |last19=Liu |first19=Lihong |last20=Siemieniuk |first20=Reed A C |title=Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline |journal=BMJ |date=6 January 2020 |volume=368 |article-number=l6722 |doi=10.1136/bmj.l6722|pmid=31907223 |doi-access=free }}</ref><ref>{{cite journal |last1=Wang |first1=Y |last2=Ye |first2=Z |last3=Ge |first3=L |last4=Siemieniuk |first4=RAC |last5=Wang |first5=X |last6=Wang |first6=Y |last7=Hou |first7=L |last8=Ma |first8=Z |last9=Agoritsas |first9=T |last10=Vandvik |first10=PO |last11=Perner |first11=A |last12=Møller |first12=MH |last13=Guyatt |first13=GH |last14=Liu |first14=L |title=Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis. |journal=BMJ (Clinical Research Ed.) |date=6 January 2020 |volume=368 |article-number=l6744 |doi=10.1136/bmj.l6744 |pmid=31907166|doi-access=free |pmc=7190057 }}</ref>
==Treatment== [[Image:GU with clip.jpg|right|thumb|Endoscopic clipping placed on a gastric ulcer at risk for bleeding]] The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood.<ref name="Overall2011"/> A number of medications may improve outcomes depending on the source of the bleeding.<ref name=Overall2011/>
===Peptic ulcers=== Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding.<ref name=Overall2011/> Proton pump inhibitor (PPI) treatment before endoscopy may decrease the need for endoscopic hemostatic treatment, however it is not clear if this treatment reduces mortality, the risk of re-bleeding, or the {{clarify|date=September 2023}} and the need for surgery.<ref name=":0">{{Cite journal |last1=Kanno |first1=Takeshi |last2=Yuan |first2=Yuhong |last3=Tse |first3=Frances |last4=Howden |first4=Colin W. |last5=Moayyedi |first5=Paul |last6=Leontiadis |first6=Grigorios I. |date=2022-01-07 |title=Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding |url= |journal=The Cochrane Database of Systematic Reviews |volume=1 |issue=1 |article-number=CD005415 |doi=10.1002/14651858.CD005415.pub4 |issn=1469-493X |pmc=8741303 |pmid=34995368}}</ref> Oral and intravenous formulations may be equivalent; however, the evidence to support this is suboptimal.<ref>{{cite journal|last=Tsoi|first=KK|author2=Hirai, HW |author3=Sung, JJ |title=Meta-analysis: comparison of oral vs. intravenous proton pump inhibitors in patients with peptic ulcer bleeding.|journal=Alimentary Pharmacology & Therapeutics|date=Aug 5, 2013|pmid=23915096|doi=10.1111/apt.12441|volume=38|issue=7|pages=721–8|s2cid=9294529|doi-access=free}}</ref> In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance.<ref name=":0" /> There is tentative evidence of benefit for tranexamic acid which inhibits clot breakdown.<ref>{{cite journal|last1=Bennett|first1=C|last2=Klingenberg|first2=SL|last3=Langholz|first3=E|last4=Gluud|first4=LL|title=Tranexamic acid for upper gastrointestinal bleeding.|journal=The Cochrane Database of Systematic Reviews|date=21 November 2014|volume=11|issue=11|article-number=CD006640|pmid=25414987|pmc=6599825|doi=10.1002/14651858.CD006640.pub3|url=https://curve.coventry.ac.uk/open/items/24ba4106-728b-4c57-981e-d42b20393a06/1/Tranexamic+acid.pdf}}{{Dead link|date=March 2023 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> Somatostatin and octreotide, while recommended for varicial bleeding, have not been found to be of general use for non variceal bleeds.<ref name=Overall2011/> After treatment of a high risk bleeding ulcer endoscopically giving a PPI once or a day rather than as an infusion appears to work just as well and is less expensive (the method may be either by mouth or intravenously).<ref>{{cite journal|last1=Sachar|first1=H|last2=Vaidya|first2=K|last3=Laine|first3=L|title=Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis.|journal=JAMA Internal Medicine|date=November 2014|volume=174|issue=11|pages=1755–62|pmid=25201154|doi=10.1001/jamainternmed.2014.4056|pmc=4415726}}</ref>
===Variceal bleeding=== For initial fluid replacement, colloids or albumin is preferred in people with cirrhosis.<ref name=Overall2011/> Medications typically include octreotide or, if not available, vasopressin and nitroglycerin to reduce portal venous pressures.<ref name=N2010/> Terlipressin appears to be more effective than octreotide, but it is not available in many areas of the world.<ref name=SIGN2008/><ref name=Io2003>{{cite journal|last=Ioannou|first=G|author2=Doust, J |author3=Rockey, DC |title=Terlipressin for acute esophageal variceal hemorrhage|journal=Cochrane Database of Systematic Reviews|year=2003|issue=1|article-number=CD002147|pmid=12535432|doi=10.1002/14651858.CD002147|editor1-last=Ioannou|editor1-first=George N|pmc=7017851}}</ref> It is the only medication that has been shown to reduce mortality in acute variceal bleeding.<ref name=Io2003/> This is in addition to endoscopic banding or sclerotherapy for the varices.<ref name=N2010/> If this is sufficient then beta blockers and nitrates may be used for the prevention of re-bleeding.<ref name=N2010/> If bleeding continues, balloon tamponade with a Sengstaken-Blakemore tube or Minnesota tube may be used in an attempt to mechanically compress the varices.<ref name=N2010/> This may then be followed by a transjugular intrahepatic portosystemic shunt.<ref name=N2010/> In those with cirrhosis, antibiotics decrease the chance of bleeding again, shorten the length of time spent in hospital, and decrease mortality.<ref name=Chavez2011/> Octreotide reduces the need for blood transfusions<ref>{{cite journal|last=Gøtzsche|first=PC|author2=Hróbjartsson, A|title=Somatostatin analogues for acute bleeding oesophageal varices|journal=Cochrane Database of Systematic Reviews|date=2008-07-16|volume=2008 |issue=3|article-number=CD000193|pmid=18677774|doi=10.1002/14651858.CD000193.pub3|editor1-last=Gøtzsche|editor1-first=Peter C|pmc=7043291}}</ref> and may decrease mortality.<ref>{{cite journal|last=Wells|first=M|author2=Chande, N |author3=Adams, P |author4=Beaton, M |author5=Levstik, M |author6=Boyce, E |author7= Mrkobrada, M |title=Meta-analysis: vasoactive medications for the management of acute variceal bleeds|journal=Alimentary Pharmacology & Therapeutics|date=June 2012|volume=35|issue=11|pages=1267–78|pmid=22486630|doi=10.1111/j.1365-2036.2012.05088.x|s2cid=41754753|doi-access=free}}</ref> No trials of vitamin K have been conducted.<ref>{{cite journal|last1=Martí-Carvajal|first1=AJ|last2=Solà|first2=I|title=Vitamin K for upper gastrointestinal bleeding in people with acute or chronic liver diseases.|journal=The Cochrane Database of Systematic Reviews|date=9 June 2015|volume=6|issue=6|article-number=CD004792|pmid=26058964|doi=10.1002/14651858.CD004792.pub5|pmc=7387129}}</ref>
===Blood products=== The evidence for benefit of blood transfusions in GI bleed is poor with some evidence finding harm.<ref name=Red2010/> In those in shock O-negative packed red blood cells are recommended.<ref name=EBMED2004/> If large amounts of pack red blood cells are used additional platelets and fresh frozen plasma (FFP) should be administered to prevent coagulopathies.<ref name=Overall2011/> In alcoholics FFP is suggested before confirmation of a coagulopathy due to presumed blood clotting problems.<ref name=EBMED2004/> Evidence supports holding off on blood transfusions in those who have a hemoglobin greater than 7 to 8 g/dL and moderate bleeding, including in those with preexisting coronary artery disease.<ref name=Wang2013/><ref name=Sal2014/>
If the INR is greater than 1.5 to 1.8 correction with fresh frozen plasma or prothrombin complex may decrease mortality.<ref name=Overall2011/> Evidence of a harm or benefit of recombinant activated factor VII in those with liver diseases and gastrointestinal bleeding is not determined.<ref>{{cite journal|last=Martí-Carvajal|first=AJ |author2=Karakitsiou, DE |author3=Salanti, G|title=Human recombinant activated factor VII for upper gastrointestinal bleeding in patients with liver diseases|journal=Cochrane Database of Systematic Reviews|date=2012-03-14|volume=3|issue=3 |article-number=CD004887|pmid=22419301|doi=10.1002/14651858.CD004887.pub3|editor1-last=Martí-Carvajal|editor1-first=Arturo J|pmc=11569891}}</ref> A massive transfusion protocol may be used, but there is a lack of evidence for this indication.<ref name=SIGN2008/>
===Procedures=== thumb|upright=1.5|The Blakemore esophageal balloon used for stopping esophageal bleeds if other measures have failed The benefits versus risks of placing a nasogastric tube in those with upper GI bleeding are not determined.<ref name=Overall2011/> Endoscopic evaluation within 24 hours is recommended,<ref name=Overall2011/> in addition to medical management.<ref>{{cite journal|last=D'Amico|first=G|author2=Pagliaro, L |author3=Pietrosi, G |author4=Tarantino, I |title=Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients|journal=Cochrane Database of Systematic Reviews|date=2010-03-17|volume=2010|issue=3|article-number=CD002233|pmid=20238318|doi=10.1002/14651858.CD002233.pub2|editor1-last=d'Amico|editor1-first=Gennaro|pmc=7100539}}</ref> A number of endoscopic treatments may be used, including: epinephrine injection, band ligation, sclerotherapy, and fibrin glue depending on what is found.<ref name=EBMED2004/> Prokinetic agents such as erythromycin before endoscopy can decrease the amount of blood in the stomach and thus improve the operators view.<ref name=Overall2011/> They also decrease the amount of blood transfusions required.<ref>{{cite journal|last=Bai|first=Y |author2=Guo, JF |author3=Li, ZS|title=Meta-analysis: erythromycin before endoscopy for acute upper gastrointestinal bleeding|journal=Alimentary Pharmacology & Therapeutics|date=July 2011|volume=34|issue=2|pages=166–71|pmid=21615438|doi=10.1111/j.1365-2036.2011.04708.x|s2cid=9906835 }}</ref> Early endoscopy decreases hospital and the amount of blood transfusions needed.<ref name=Overall2011/> A second endoscopy within a day is routinely recommended by some<ref name=SIGN2008/> but by others only in specific situations.<ref name=IC2010>{{cite journal |vauthors=Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, Sinclair P |title=International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding |journal=Ann. Intern. Med. |volume=152 |issue=2 |pages=101–13 |year=2010 |pmid=20083829 |doi=10.7326/0003-4819-152-2-201001190-00009 |doi-access=free }}</ref> Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found.<ref name=Overall2011/> High and low dose PPIs appear equivalent at this point.<ref>{{cite journal|last=Wu|first=LC |author2=Cao, YF |author3=Huang, JH |author4=Liao, C |author5=Gao, F|title=High-dose vs low-dose proton pump inhibitors for upper gastrointestinal bleeding: a meta-analysis|journal=World Journal of Gastroenterology|date=2010-05-28|volume=16|issue=20|pages=2558–65|pmid=20503458|pmc=2877188|doi=10.3748/wjg.v16.i20.2558 |doi-access=free }}</ref> It is also recommended that people with high risk signs are kept in hospital for at least 72 hours.<ref name=Overall2011/> Those at low risk of re-bleeding may begin eating typically 24 hours following endoscopy.<ref name=Overall2011/> If other measures fail or are not available, esophageal balloon tamponade may be attempted.<ref name=EBMED2004/> While there is a success rate up to 90%, there are some potentially significant complications including aspiration and esophageal perforation.<ref name=EBMED2004/>
Colonoscopy is useful for the diagnosis and treatment of lower GI bleeding.<ref name=EBMED2004/> A number of techniques may be employed including clipping, cauterizing, and sclerotherapy.<ref name=EBMED2004/> Preparation for colonoscopy takes a minimum of six hours which in those bleeding briskly may limit its applicability.<ref>{{cite web|title=Management of acute lower GI bleeding|url=http://www.guideline.gov/content.aspx?id=14791|work=University of Pennsylvania Health System (UPHS).|page=6|date=Jan 2009|archive-url=https://web.archive.org/web/20130220000207/http://www.guideline.gov/content.aspx?id=14791|archive-date=2013-02-20|access-date=2012-04-23}}</ref> Surgery, while rarely used to treat upper GI bleeds, is still commonly used to manage lower GI bleeds by cutting out the part of the intestines that is causing the problem.<ref name=EBMED2004/> Angiographic embolization may be used for both upper and lower GI bleeds.<ref name=EBMED2004/> Transjugular intrahepatic portosystemic shunting (TIPS) may also be considered.<ref name=SIGN2008/>
==Prognosis== Death in those with a GI bleed is more commonly due to other illnesses (some of which may have contributed to the bleed, such as cancer or cirrhosis) than the bleeding itself.<ref name=EBMED2004/> Of those admitted to a hospital because of a GI bleed, death occurs in about 7%.<ref name=SIGN2008>{{cite journal|last=Palmer|first=K|author2=Nairn, M|author3=Guideline Development, Group|title=Management of acute gastrointestinal blood loss: summary of SIGN guidelines|journal=BMJ (Clinical Research Ed.)|date=2008-10-10|volume=337|article-number=a1832|pmid=18849311|url=http://www.sign.ac.uk/pdf/sign105.pdf|doi=10.1136/bmj.a1832|s2cid=30762576|archive-url=https://web.archive.org/web/20120616223232/http://www.sign.ac.uk/pdf/sign105.pdf|archive-date=2012-06-16|access-date=2013-01-18}}</ref> Despite treatment, re-bleeding occurs in about 7–16% of those with upper GI bleeding.<ref name=Epi2008/> In those with esophageal varices, bleeding occurs in about 5–15% a year and if they have bled once, there is a higher risk of further bleeding within six weeks.<ref name=N2010/> Testing and treating ''H. pylori'' if found can prevent re-bleeding in those with peptic ulcers.<ref name=Overall2011/> The benefits versus risks of restarting blood thinners such as aspirin or warfarin and anti-inflammatories such as NSAIDs need to be carefully considered.<ref name=Overall2011/> If aspirin is needed for cardiovascular disease prevention, it is reasonable to restart it within seven days in combination with a PPI for those with nonvariceal upper GI bleeding.<ref name=IC2010/>
==Epidemiology== Gastrointestinal bleeding from the upper tract occurs in 50 to 150 per 100,000 adults per year.<ref name=Red2010/> It is more common than lower gastrointestinal bleeding which is estimated to occur at the rate of 20 to 30 per 100,000 per year.<ref name=EBMED2004/> Risk of bleeding is more common in males and increases with age.<ref name=EBMED2004/>
==References== {{Reflist}}
==External links== * {{cite web | url = https://medlineplus.gov/gastrointestinalbleeding.html | publisher = U.S. National Library of Medicine | work = MedlinePlus | title = Gastrointestinal Bleeding }}
{{Gastroenterology}} {{Bleeding and clotting disorders|us=y}} {{Medical resources | DiseasesDB = 19317 | ICD10 = {{ICD10|K|92|2|k|90}} | ICD9 = {{ICD9|578.9}} | ICDO = | OMIM = | MedlinePlus = 003133 | eMedicineSubj = radio | eMedicineTopic = 301 | eMedicine_mult = {{eMedicine2|radio|302}} {{eMedicine2|emerg|381}} | MeshID = D006471
}} {{Authority control}}
Category:Bleeding Category:Conditions diagnosed by stool test Category:Gastrointestinal tract disorders Category:Wikipedia medicine articles ready to translate Category:Wikipedia emergency medicine articles ready to translate Category:Transfusion medicine