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Introduction
Gastrointestinal (GI) bleeding can be categorised into two main types: upper and lower. The anatomic landmark that distinguishes the two is the suspensory ligament of the duodenum (Ligament of Treitz).
Bleeding originating proximal to the ligament of Treitz is classified as ‘upper GI bleeding’ and typically presents with haematemesis or melaena.
Bleeding distal to the ligament is classified as ‘lower GI bleeding’ and commonly presents with haematochezia.
Other clinical features common to both upper and lower GI bleeding may include anaemia, abdominal pain, and signs of hypovolemic shock.
Table 1. Haematemesis vs melaena vs haematochezia.
| Definition | Overview | Location |
| Haematemesis | Vomiting of blood; may be obviously red or have an appearance similar to ‘coffee grounds’ when partially digested. | Upper GI |
| Melaena | The passage of black, tarry stools. Characteristic smell and appearance due to the digestion of haemoglobin by digestive enzymes and intestinal flora. | Upper GI Less commonly, can be seen in small bowel and right-sided colon bleeds |
|
Haematochezia |
The passage of fresh blood per anus, usually in or with stools | Lower GI Importantly, rapid passage of blood from the upper GI tract may also result in haematochezia |
Aetiology
Patients may have clinical signs of the underlying condition causing gastrointestinal bleeding (e.g. ascites and jaundice in advanced liver cirrhosis).
Table 2. Causes of bleeding from the upper gastrointestinal tract.
| Upper GI tract | Causes |
| Oesophagus |
|
| Stomach |
|
| Small intestine (duodenum) |
|
Table 3. Causes of bleeding from the lower gastrointestinal tract.
| Lower GI tract | Causes |
| Small intestine (jejunum, ileum) |
|
| Colon and rectum |
|
| Anus |
Management
Patients with gastrointestinal bleeding should be managed according to an ABCDE approach, with prompt resuscitation to restore and maintain normal blood volume. A history should be taken to help determine the source of the bleeding and potential causes.
Once the bleeding site has been established, a treatment regime can be commenced.
Upper GI bleeding
In cases of suspected upper GI bleeding, oesophago-gastroduodenoscopy (OGD) is the diagnostic modality of choice and is also therapeutic.
Upper endoscopy allows for the visualisation of the bleeding site and direct intervention (e.g. haemostatic clips). Additionally, patients with upper GI bleeding may also benefit from various pharmacological therapies (e.g. proton pump inhibitions in peptic ulcer disease).
The Glasgow-Blatchford Score is a pre-endoscopy scoring tool for identifying low-risk patients, and the Rockall score is a post-endoscopy risk stratification tool.
Lower GI bleeding
Coloscopy is the diagnostic and therapeutic modality of choice for suspected lower GI bleeding.
Similarly to OGD, it allows direct visualisation of the bleeding source and intervention (e.g. electrocautery). In cases where colonoscopy fails, or there is ongoing GI bleeding and haemodynamic instability refractory to resuscitation, angiography may be considered.
The management of lower GI bleeds is typically surgical to treat any bleeds mechanically. There are few validated scoring tools for lower GI bleeding; however, consider condition-specific risk stratification and follow local guidelines.
