Gastrointestinal (GI) bleeding is a common clinical problem that requires more than 300,000 hospitalizations annually in the United States. Most bleeding episodes resolve spontaneously; however, patients with severe and persistent bleeding have high mortality rates. Evaluation of a patient with bleeding begins with assessment of the urgency of the situation. Resuscitation with intravenous fluids and blood products is the first consideration. Once the patient’s condition is stable, a brief history and physical examination help determine the location of the bleeding. For probable or known upper GI bleeding, a nasogastric tube is placed to help determine the location of bleeding and to monitor the rapidity of the bleeding. The following algorithm is a general guideline for evaluation of nonvar-iceal upper GI bleeding.
Patients with liver disease or other causes of portal hypertension have a potential variceal source of
hemorrhage. Urgent diagnostic endoscopy is indicated to confirm the bleeding source, because between one third and one half of these patients have bleeding from nonvariceal sites, and future management is different for bleeding varices. The following algorithm is for the evaluation and management of variceal hemorrhage. TIPS indicates trans- jugular intrahepatic portosystemic shunt.
When the location of bleeding is suspected to be the lower GI tract, a nasogastric (NG) tube and even upper endoscopy may still be needed to rule out an upper GI source of hemorrhage. It is important to remember that as many as 10% of patients with hematochezia have an upper GI source and that results of nasogastric aspiration can be falsely negative when bleeding is duodenal and there is no duodenogastric reflux or when the bleeding has ceased. The following algorithm is proposed for evaluation of lower GI bleeding.
Unfortunately, some patients have both upper and lower GI bleeding sites that defy diagnosis despite the numerous diagnostic modalities available. They need repeated studies if bleeding recurs or becomes a management problem.
hemorrhage. Urgent diagnostic endoscopy is indicated to confirm the bleeding source, because between one third and one half of these patients have bleeding from nonvariceal sites, and future management is different for bleeding varices. The following algorithm is for the evaluation and management of variceal hemorrhage. TIPS indicates trans- jugular intrahepatic portosystemic shunt.
When the location of bleeding is suspected to be the lower GI tract, a nasogastric (NG) tube and even upper endoscopy may still be needed to rule out an upper GI source of hemorrhage. It is important to remember that as many as 10% of patients with hematochezia have an upper GI source and that results of nasogastric aspiration can be falsely negative when bleeding is duodenal and there is no duodenogastric reflux or when the bleeding has ceased. The following algorithm is proposed for evaluation of lower GI bleeding.
Unfortunately, some patients have both upper and lower GI bleeding sites that defy diagnosis despite the numerous diagnostic modalities available. They need repeated studies if bleeding recurs or becomes a management problem.
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