Updated March 2017
- Important site of occult bleeding. Significant blood loss may occur
before bleeding is apparent.
- Although relatively uncommon in the ICU population, chronic GI bleeding
should always be considered as a cause of unexplained anaemia
- Classified into:
- Upper - bleeding proximal to ligament of Treitz
- Middle - bleeding from small intestine distal to ligament of
- Lower - bleeding from large intestine
Immediate management of overt GI bleeding
- Assess severity of shock and start rapid fluid resuscitation with IV
- If blood transfusion of >3 units is expected, order platelets and fresh
frozen plasma from the start. Ratio of blood:plasma:platelets is unclear.
Trauma data suggest there is no advantage of 1:1:1 over 2:1:1
- 1:1:1 ratio may not be appropriate in patients with cardiac failure
or patients with variceal bleeding, in whom excessive transfusion may
markedly raise portal venous pressure resulting in increased bleeding
- A restrictive transfusion policy aiming for a Hb ≥7 g/dl is associated
with a lower mortality in patients with upper GI bleeding(but note that this
study excluded patients with immediately life threatening haemorrhage and
patients with acute coronary syndrome). May not be appropriate in whom
definitive treatment to stop the bleeding will be delayed.
- Keep INR, APTT and PT ≤1.5 times
upper limit of normal, fibrinogen >1.5 g/l and platelet count >50 x 109/l
- The appropriate target blood pressure is unclear but a systolic pressure
of 90 mmHg is probably satisfactory provided this results in adequate tissue
perfusion AND early definitive treatment to stop the bleeding is planned
- Determine whether the patient needs intubation for airway protection.
This needs to be repeatedly assessed.
- Recurrent haematemesis
- Decreased consciousness
- Requires sedation for endoscopy
- Determine whether the bleeding is coming from the upper GI tract
(proximal to the ligament of Treitz), middle (small bowel distal to ligament
of Treitz) or the lower GI tract (large bowel) as this will determine the
appropriate definitive management.
||Upper GI bleeding
||Lower GI bleeding
||Overall, 60-80% of GI bleeding but probably higher in patients
presenting to ICU as upper GI bleeding more likely to be severe
Coffee ground vomitus
Previous upper GI bleed
Peptic ulcer disease
|Fresh blood PR
Altered blood mixed with stool
|Fresh blood PR in the presence of severe shock may be
the result of massive upper GI bleeding with a rapid transit time
through the gut.
Occasionally melaena may be due to colonic bleeding
||Active bowel sounds
Fresh blood or coffee grounds aspirated from nasogastric tube.
|Quiet or absent bowel sounds
||The absence of coffee grounds or blood in the NG
aspirate does not exclude upper GI bleeding, especially in the absence
of bile in the aspirate. It may simply be the result of a closed pylorus
preventing reflux of blood into the stomach.
||Urea:creatinine ratio>100 (SI units)
BUN:creatinine ratio >30 (mg/dl)
- Unless the bleeding is clearly lower GI, give IV bolus of proton pump
inhibitor. This has been shown to reduce the need for repeated endoscopy
(but does not reduce mortality, re-bleeding or need for surgery).
For details of further management see
Upper GI bleeding and
Lower GI bleeding
and Desborough MJR. Modern management of upper gastrointestinal haemorrhage.
Transfusion Medicine, 2015; 351-7