GI Bleeding
Gastrointestinal Bleeding
Upper, lower, and obscure GI bleeding evaluation and management — Dr. Azaan Ramani, DO across the Dallas–Fort Worth metroplex.
GI bleeding ranges from frank hemorrhage requiring hospitalization to occult bleeding discovered only on stool tests or low iron labs. Modern GI care uses risk stratification, timely endoscopy, and source-directed treatment to optimize outcomes.
Categories of GI Bleeding
Upper GI bleeding (UGIB)
Bleeding from above the ligament of Treitz (esophagus, stomach, duodenum). Presents with hematemesis (vomiting blood), 'coffee-ground' emesis, or melena (black, tarry stools). Common causes:
- Peptic ulcer disease (gastric or duodenal ulcer)
- Esophageal or gastric varices (in cirrhosis)
- Mallory-Weiss tear
- Gastritis or esophagitis
- Gastric or esophageal cancer
- Dieulafoy lesion or angiodysplasia
Lower GI bleeding (LGIB)
Bleeding from below the ligament of Treitz (small bowel, colon, rectum, anus). Typically presents with hematochezia (bright red blood per rectum). Common causes:
- Diverticular bleeding
- Hemorrhoids and anal fissures
- Colon polyps and cancer
- Vascular ectasias / angiodysplasia
- Inflammatory bowel disease
- Ischemic colitis
- Post-polypectomy bleeding
- Radiation proctitis
Occult and obscure GI bleeding
- Occult: blood loss not visible — detected by stool tests or iron-deficiency anemia. Workup follows the iron-deficiency anemia pathway
- Obscure: persistent or recurrent bleeding with negative bidirectional endoscopy. Small bowel is the source in most cases — evaluated with video capsule endoscopy and deep enteroscopy
Initial Management of Acute GI Bleeding
Acute GI bleeding is a medical emergency. Initial steps include:
- Hemodynamic resuscitation with IV fluids; transfusion when indicated
- Risk stratification (Glasgow-Blatchford, Rockall, AIMS65 scores for UGIB; Oakland score for LGIB)
- IV PPI for suspected upper GI bleeding
- Octreotide and antibiotics for suspected variceal bleeding (cirrhosis)
- Holding antiplatelets and anticoagulants when feasible — coordinated with cardiology when applicable
Endoscopic Evaluation and Treatment
Per ACG and AGA guidelines:
- Upper endoscopy within 24 hours for UGIB after initial resuscitation
- Earlier endoscopy (within 12 hours) for hemodynamically unstable patients with suspected variceal bleeding
- Colonoscopy for LGIB after stabilization, typically within 24 hours of admission for severe ongoing bleeding
Endoscopic hemostasis options include thermal therapy, mechanical clips, hemostatic powders, band ligation (for varices), and injection therapy. Most non-variceal upper GI bleeding stops with endoscopic therapy alone.
Outpatient Workup for Visible or Occult Bleeding
Patients with stable bleeding — visible blood in the stool, melena that has resolved, or occult blood loss with low iron — are typically evaluated as outpatients:
- Bidirectional endoscopy (EGD + colonoscopy) for unexplained iron-deficiency anemia or melena with stable hemodynamics
- Colonoscopy alone for hematochezia in patients with low risk of upper source
- Video capsule endoscopy when bidirectional endoscopy is non-diagnostic
Visible rectal bleeding — even when assumed to be hemorrhoids — should not be ignored, especially over age 40, with new symptoms, family history of CRC, or weight loss. See the colon cancer screening page.
GI Bleeding: Common Questions
When is GI bleeding an emergency?
Go to the ED for: vomiting blood, persistent black tarry stools, large-volume rectal bleeding, lightheadedness, fainting, or fast heart rate. Chronic mild bleeding warrants prompt outpatient evaluation.
Is bright red blood from below always hemorrhoids?
No — hemorrhoids and fissures are common, but colon cancer, polyps, diverticular bleeding, IBD, and angiodysplasia present the same way. Never assume hemorrhoids without evaluation — especially over 40, with new symptoms, family history, or weight loss.
What is melena?
Melena is dark, sticky, tarry stool from digested blood — typically from upper GI bleeding. Distinguish from dark stool from iron supplements or Pepto-Bismol. Warrants prompt GI evaluation; large volumes or symptoms warrant ED visit.
What causes diverticular bleeding?
Diverticulosis = small outpouchings in the colon wall, common with age. Diverticular bleeding is a leading cause of significant lower GI bleeding in older adults — typically painless, large-volume bright red bleeding. About 75% stops spontaneously; the rest need endoscopic, angiographic, or surgical treatment.
What are esophageal varices?
Varices are dilated esophageal/gastric veins from cirrhosis and portal hypertension — potentially life-threatening. AASLD recommends variceal screening in cirrhosis. Prophylaxis: non-selective beta-blockers or band ligation. Active bleeding: octreotide + antibiotics + band ligation.
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