Massive gastrointestinal (GI) bleeding is an emergency. The spectrum of disease is broad and requires critical steps in evaluation and assessment, as well as rapid stabilization and involvement of consultants for intervention. Patients with specific risk factors (including liver disease and anticoagulant use) are at increased risk of morbidity and mortality.
- Initial evaluation should prioritize airway, breathing, and circulation (ABCs) with attention to possible sources of bleeding.
- Establish intravenous (IV) access with 2 peripheral large-bore cannulas and begin fluid resuscitation immediately.
- Early and aggressive blood transfusion is encouraged.
- Have a low threshold to initiate massive transfusion protocol.
- The patient should be given nothing by mouth.
- Balloon tamponade devices can be considered as a temporizing measure particularly in patients with suspected esophageal varices.
- Reversal of any anticoagulant or antiplatelet medications should be considered and initiated promptly.
GI bleeding is defined as loss of blood from any portion of the GI tract, from mouth to anus. Upper GI bleeds are those where the source of bleeding is proximal to the ligament of Treitz (suspensory muscle of the duodenum), whereas lower GI bleeds originate distal to this area. The definition of massive GI bleed is less well defined but generally refers to any bleeding with loss of one-quarter to one-third of blood volume OR findings consistent with shock.
Upper GI bleeds are further classified as nonvariceal (~90%) or variceal bleeds (~10%). They carry an overall mortality of approximately 10%. The incidence for upper GI bleeds is 67/100 000. Lower GI bleeds are less common (37/100 000) and carry a mortality rate of approximately 3.5%. The etiologies of GI bleeding hemorrhage are varied, but the most common include peptic ulcer disease, variceal bleeding, vascular abnormalities, and diverticular disease. These etiologies as well as predisposing conditions are listed in the Differential Diagnosis section. GI hemorrhage is more common in males than in females and generally occurs in individuals older than 50 years, but it can be seen in younger populations and even neonates.
The classic findings in GI bleeding are hematemesis (or bloody vomiting), melena (black, "tarry" stools), or hematochezia (bright red blood in stool). The presence of melena in stools suggests an upper GI or proximal lower GI bleed, as this indicates the blood has oxidized. Hematochezia is usually associated with lower GI bleeding but can also be seen in brisk upper GI bleeding. Symptoms of massive GI bleeding are consistent with those of shock, including hypotension, pallor, cool skin, tachycardia, and altered mental status.
