# Clinical Cases: GI Bleeding

## Case 1: Upper GI Bleeding - Peptic Ulcer Disease

### Patient Presentation
A 58-year-old man presents with one episode of vomiting bright red blood followed by several episodes of maroon-colored stools over the past 6 hours. He reports epigastric pain for the past 2 weeks that he has been treating with ibuprofen. He has a history of osteoarthritis and takes daily ibuprofen and low-dose aspirin for cardiovascular protection. He denies alcohol use.

### Vital Signs
- Blood Pressure: 92/58 mmHg
- Heart Rate: 118 bpm
- Respiratory Rate: 20/min
- Oxygen Saturation: 97% on room air
- Temperature: 36.8°C
- Orthostatic changes: Yes (HR increases 30 bpm when standing)

### Physical Examination
- General: Pale, diaphoretic, anxious
- Cardiovascular: Tachycardic, regular rhythm
- Abdomen: Soft, mild epigastric tenderness, no guarding or rigidity
- Rectal exam: Maroon stool, guaiac positive

### Initial Workup
- **Hemoglobin**: 7.2 g/dL (baseline unknown)
- **Platelets**: 245,000/μL
- **BUN**: 42 mg/dL
- **Creatinine**: 1.1 mg/dL
- **INR**: 1.0
- **Type and screen**: Ordered

### Clinical Image
![Bleeding Peptic Ulcer](image_01.png)
*Figure 1: Endoscopic image of a bleeding gastric ulcer with a visible vessel (Forrest classification Ia - active spurting), requiring urgent endoscopic intervention.*

**Image Source**: Educational illustration for teaching purposes.

### Questions

1. **What is this patient's Glasgow-Blatchford Score (GBS) and what does it indicate?**
   - A) Low score indicating possible outpatient management
   - B) High score indicating need for intervention
   - C) Score used only for lower GI bleeding
   - D) Score used only after endoscopy

2. **What are the priorities of initial resuscitation?**
   - A) Immediate endoscopy
   - B) IV access, fluid resuscitation, blood transfusion, monitoring
   - C) CT angiography
   - D) Oral PPI therapy

3. **When should endoscopy be performed in upper GI bleeding?**
   - A) Within 48 hours for all patients
   - B) Emergent (<12 hours) if hemodynamically unstable; within 24 hours for most patients with UGIB
   - C) Only after complete bowel prep
   - D) After 72 hours of PPI therapy

4. **What is the role of proton pump inhibitors in UGIB?**

5. **What is the Forrest classification and how does it guide management?**

### Answers

1. **B) High score indicating need for intervention** - The Glasgow-Blatchford Score uses admission data (BUN, hemoglobin, systolic BP, heart rate, presence of melena/syncope, hepatic disease, cardiac failure) to predict need for intervention. This patient has elevated BUN, low hemoglobin, tachycardia, hypotension, and melena - indicating high risk.

2. **B) IV access, fluid resuscitation, blood transfusion, monitoring** - Initial management:
   - Two large-bore IV lines
   - Crystalloid resuscitation
   - Packed RBCs if hemoglobin <7 g/dL (or <8 in cardiovascular disease)
   - Correct coagulopathy if present
   - ICU monitoring if hemodynamically unstable

3. **B) Emergent (<12 hours) if hemodynamically unstable; within 24 hours for most patients with UGIB** - Urgent endoscopy (<24 hours) is standard for UGIB. Emergent endoscopy (<12 hours) is indicated for persistent hemodynamic instability despite resuscitation.

4. **Role of PPIs in UGIB**:
   - High-dose IV PPI (pantoprazole 80 mg bolus, then 8 mg/hour infusion) after endoscopy for high-risk ulcers
   - Reduces re-bleeding, need for surgery, and mortality
   - Pre-endoscopic PPI may downstage lesions but does not improve mortality
   - Transition to oral PPI after 72 hours of IV therapy
   - Continue PPI therapy long-term for peptic ulcer disease

5. **Forrest classification**:
   - **Ia**: Active spurting - 90% re-bleed risk - needs endoscopic therapy
   - **Ib**: Active oozing - 50% re-bleed risk - needs endoscopic therapy
   - **IIa**: Visible vessel - 43% re-bleed risk - needs endoscopic therapy
   - **IIb**: Adherent clot - 22% re-bleed risk - consider removing clot
   - **IIc**: Flat pigmented spot - 10% re-bleed risk - no endoscopic therapy
   - **III**: Clean base - <5% re-bleed risk - can feed, consider discharge

---

## Case 2: Lower GI Bleeding - Diverticular Hemorrhage

### Patient Presentation
A 72-year-old woman presents with large volume bright red blood per rectum that started 3 hours ago. She has passed three bowel movements of predominantly blood with clots. She denies abdominal pain, nausea, or vomiting. Past medical history includes hypertension, diverticulosis found on colonoscopy 5 years ago, and atrial fibrillation for which she takes apixaban.

### Vital Signs
- Blood Pressure: 105/68 mmHg
- Heart Rate: 102 bpm
- Respiratory Rate: 18/min
- Oxygen Saturation: 98% on room air
- Temperature: 37.0°C

### Physical Examination
- General: Alert, pale
- Cardiovascular: Irregularly irregular rhythm
- Abdomen: Soft, non-tender, no masses
- Rectal exam: Gross blood, no masses

### Laboratory Results
- **Hemoglobin**: 9.2 g/dL (baseline 12.8)
- **Platelets**: 198,000/μL
- **BUN**: 18 mg/dL
- **Creatinine**: 0.9 mg/dL
- **INR**: 1.8 (on apixaban)

### Clinical Image
![Diverticular Bleeding](image_02.png)
*Figure 2: Colonoscopic image showing a diverticulum with stigmata of recent bleeding, the most common cause of significant lower GI bleeding in elderly patients.*

**Image Source**: Educational illustration for teaching purposes.

### Questions

1. **How does lower GI bleeding typically differ from upper GI bleeding in presentation?**
   - A) Always painless
   - B) Hematochezia (bright red blood), usually painless, BUN/Cr ratio normal
   - C) Always associated with abdominal pain
   - D) Always requires surgery

2. **What is the most common cause of significant lower GI bleeding in elderly patients?**
   - A) Hemorrhoids
   - B) Colorectal cancer
   - C) Diverticular hemorrhage
   - D) Angiodysplasia

3. **How should anticoagulation be managed in this patient?**
   - A) Continue apixaban
   - B) Hold anticoagulation, consider reversal agent (andexanet alfa) if severe bleeding
   - C) Switch to warfarin
   - D) Give additional anticoagulation

4. **What is the role of colonoscopy in lower GI bleeding?**

5. **When is angiography or surgery indicated for lower GI bleeding?**

### Answers

1. **B) Hematochezia (bright red blood), usually painless, BUN/Cr ratio normal** - Lower GI bleeding presents with bright red blood or maroon stool. BUN is typically not elevated (no protein digestion). Note: Brisk upper GI bleeding can also present with hematochezia.

2. **C) Diverticular hemorrhage** - Diverticular bleeding is the most common cause of major lower GI bleeding in elderly patients. Bleeding occurs when a vessel in the diverticulum wall (vasa recta) erodes. Most (80-85%) stop spontaneously.

3. **B) Hold anticoagulation, consider reversal agent (andexanet alfa) if severe bleeding** - For significant bleeding, anticoagulants should be held. Reversal agents (andexanet alfa for factor Xa inhibitors, idarucizumab for dabigatran) may be considered for life-threatening bleeding. Restart anticoagulation once bleeding controlled, weighing thrombotic risk.

4. **Role of colonoscopy in lower GI bleeding**:
   - Diagnostic: Identifies source in majority of cases
   - Therapeutic: Can treat bleeding with clips, thermal therapy, or injection
   - Timing: Within 24 hours after adequate bowel prep for hospitalized patients
   - Urgent colonoscopy (within 12 hours) has not shown improved outcomes over standard timing
   - Requires bowel preparation for adequate visualization

5. **Indications for angiography or surgery**:
   - **CT angiography**: If massive bleeding (≥0.5 mL/min) precluding colonoscopy
   - **Conventional angiography**: If CTA shows active extravasation - allows embolization
   - **Surgery**: Refractory bleeding despite endoscopic and angiographic intervention
   - Consider surgery earlier if transfusion requirement >6 units in 24 hours

---

## Case 3: Variceal Hemorrhage

### Patient Presentation
A 55-year-old man with known alcohol-related cirrhosis (Child-Pugh B) presents with massive hematemesis. He has vomited approximately 500 mL of blood en route to the hospital. He was not compliant with his variceal surveillance and has not seen a gastroenterologist in 2 years. He reports continued alcohol use.

### Vital Signs
- Blood Pressure: 82/48 mmHg
- Heart Rate: 128 bpm
- Respiratory Rate: 26/min
- Oxygen Saturation: 92% on room air
- Temperature: 36.5°C

### Physical Examination
- General: Somnolent, icteric
- HEENT: Blood in oropharynx
- Cardiovascular: Tachycardic, weak pulses
- Abdomen: Distended with ascites, caput medusae, splenomegaly
- Extremities: 2+ edema, spider angiomata
- Neurologic: Lethargic, asterixis present

### Laboratory Results
- **Hemoglobin**: 6.8 g/dL
- **Platelets**: 68,000/μL
- **INR**: 1.9
- **Bilirubin**: 4.2 mg/dL
- **Albumin**: 2.4 g/dL
- **Creatinine**: 1.8 mg/dL (baseline 1.0)

### Clinical Image
![Esophageal Varices](image_03.png)
*Figure 3: Endoscopic image of large esophageal varices with red wale signs (longitudinal red streaks), indicating high risk of bleeding.*

**Image Source**: Educational illustration for teaching purposes.

### Questions

1. **What pharmacologic therapy should be initiated immediately for suspected variceal bleeding?**
   - A) Proton pump inhibitor only
   - B) Octreotide (or terlipressin) plus antibiotics (ceftriaxone)
   - C) Vasopressin
   - D) Beta-blocker

2. **What is the target hemoglobin for transfusion in variceal bleeding?**
   - A) >10 g/dL
   - B) 7-8 g/dL (restrictive transfusion)
   - C) >12 g/dL
   - D) >9 g/dL

3. **When should endoscopy be performed in suspected variceal bleeding?**
   - A) After 24 hours of stabilization
   - B) Within 12 hours of presentation
   - C) Only if octreotide fails
   - D) After correcting coagulopathy completely

4. **Why are prophylactic antibiotics important in variceal bleeding?**

5. **What rescue therapy is available if endoscopic treatment fails?**

### Answers

1. **B) Octreotide (or terlipressin) plus antibiotics (ceftriaxone)** - Vasoactive drugs (octreotide 50 mcg bolus then 50 mcg/hour) reduce splanchnic blood flow and portal pressure. Prophylactic antibiotics (ceftriaxone 1g IV daily) reduce bacterial translocation, SBP risk, and mortality.

2. **B) 7-8 g/dL (restrictive transfusion)** - Restrictive transfusion (target Hgb 7-8 g/dL) is associated with better outcomes in variceal bleeding than liberal transfusion. Over-transfusion can increase portal pressure and re-bleeding risk.

3. **B) Within 12 hours of presentation** - Early endoscopy (within 12 hours) allows diagnosis and treatment with band ligation (preferred) or sclerotherapy. Intubation for airway protection may be needed before endoscopy in patients with altered consciousness.

4. **Importance of prophylactic antibiotics**:
   - Cirrhotic patients have impaired immune function and gut barrier
   - Bleeding promotes bacterial translocation
   - Antibiotics reduce infections (SBP, pneumonia, UTI) from 45% to 14%
   - Reduce mortality and re-bleeding
   - Ceftriaxone 1g IV daily for 7 days (or norfloxacin if no IV access)

5. **Rescue therapy for refractory variceal bleeding**:
   - **Balloon tamponade**: Sengstaken-Blakemore or Minnesota tube (temporizing measure, max 24 hours)
   - **TIPS (Transjugular Intrahepatic Portosystemic Shunt)**: Creates portosystemic shunt to decompress varices
   - **Self-expanding esophageal stent**: Alternative to balloon tamponade
   - **Surgery**: Rarely needed; portocaval shunt or devascularization
   - Early TIPS (within 72 hours) improves outcomes in high-risk patients

---

## Learning Points

1. **Risk stratification** using Glasgow-Blatchford Score (UGIB) guides management intensity and timing of endoscopy.

2. **Resuscitation** with IV fluids and blood transfusion (target Hgb 7-8 g/dL) precedes definitive diagnosis in hemodynamically unstable patients.

3. **Upper GI bleeding** typically presents with hematemesis or melena, elevated BUN/Cr ratio; lower GI bleeding presents with hematochezia and normal BUN.

4. **Variceal bleeding** requires vasoactive drugs (octreotide), antibiotics, restrictive transfusion, and urgent endoscopy with band ligation.

5. **Anticoagulation management** in GI bleeding requires balancing bleeding risk against thromboembolic risk; reversal agents are available for life-threatening hemorrhage.