Gastrointestinal bleeding

Abstract

Gastrointestinal bleeding (GIB) is a common emergency, which can be subdivided into upper and lower, and acute or chronic, with acute upper GIB further subdivided into variceal (11%) and nonvariceal (89%) bleeding. Risk stratification in acute upper GIB can be performed using simple clinical and endoscopic criteria that can be used to estimate the risk of mortality, but there are no validated systems for use in acute lower GIB. The immediate management of the hypovolaemic patient is first directed towards resuscitation and then to identification of the site and cause of bleeding. Most patients will stop bleeding spontaneously and should then be investigated with either upper gastrointestinal endoscopy or colonoscopy as appropriate. Patients with acute ongoing upper GIB require urgent investigation by oesophagogastroduodenoscopy with a view to applying endoscopic haemostatic therapy, which is efficacious in up to 95% of patients. High-dose proton pump inhibitor treatment should be given following successful endoscopic therapy to patients with major ulcer bleeding. If these techniques fail to arrest bleeding, then either selective mesenteric angiography with embolization or surgery is indicated. Patients who are unstable with acute lower GIB require early oesophagogastroduodenoscopy (to exclude an upper gastrointestinal cause) and then an interventional radiological procedure to embolize the bleeding vessel(s); surgery is generally a last resort.