Overview of GI Bleeding
Gastrointestinal bleeding is any bleeding originating in the digestive tract — anywhere from the mouth and esophagus to the anus. It is one of the most common GI emergencies, accounting for a substantial proportion of acute hospital admissions, and ranges from minor self-limiting bleeds to life-threatening haemorrhage requiring resuscitation and intervention.
Modern management of GI bleeding is multidisciplinary. Most bleeds are now controlled by endoscopic therapy performed by an interventional endoscopist, with interventional radiology (transcatheter embolisation) as second-line when endoscopy is unsuccessful, and surgical haemostasis reserved for failures of these less-invasive approaches and for definitive treatment of the underlying disease. Dr A K Bansal's service covers the surgical arm of this pathway, with close working relationships with hepatology, interventional endoscopy and interventional radiology colleagues.
Care follows the ESGE (European Society of Gastrointestinal Endoscopy), BSG (British Society of Gastroenterology), ACG (American College of Gastroenterology), WSES (World Society of Emergency Surgery) and AASLD/AGA guidelines on the management of acute GI bleeding and variceal haemorrhage.
Classification
GI bleeding is classified by site and by clinical pattern:
By site:
- Upper GI bleeding (UGIB): bleeding from a source proximal to the ligament of Treitz — esophagus, stomach, duodenum
- Mid GI bleeding: bleeding from the small bowel (jejunum, ileum)
- Lower GI bleeding (LGIB): bleeding from the colon, rectum or anus
By clinical pattern:
- Overt bleeding: visible blood — hematemesis, melena, hematochezia
- Occult bleeding: not visible but detected on testing (faecal occult blood test, iron-deficiency anaemia)
- Obscure bleeding: recurrent bleeding with no source found on conventional upper GI endoscopy and colonoscopy — typically requires small bowel investigation
Symptoms & Presentation
- Hematemesis — vomiting fresh red blood or coffee-ground material (upper GI bleed)
- Melena — black tarry sticky stool, characteristic odour (typically upper GI bleed; occasionally distal small bowel or right colon)
- Hematochezia — fresh red blood per rectum (typically lower GI bleed; massive upper GI bleed can also cause hematochezia)
- Maroon stool — typically mid- to right colonic bleeding
- Iron-deficiency anaemia, fatigue, breathlessness — chronic occult bleeding
- Shock — dizziness, syncope, fast pulse, low blood pressure, pallor, sweating — major haemorrhage
Seek emergency care immediately for: vomiting fresh blood, large black tarry stools, large amounts of red blood per rectum, fainting, dizziness or weakness with these symptoms. GI bleeding can be rapidly life-threatening. Do not delay.
Causes of Upper GI Bleeding
- Peptic ulcer disease (gastric and duodenal ulcers) — approximately 40–50% of UGIB
- Esophageal and gastric varices — particularly in patients with liver cirrhosis
- Erosive gastritis and esophagitis — including NSAID-related
- Mallory-Weiss tear — longitudinal mucosal tear at the gastro-esophageal junction following forceful vomiting
- Dieulafoy's lesion — submucosal aberrant artery that erodes through normal mucosa
- Upper GI malignancy — stomach cancer, esophageal cancer, GIST
- GAVE (gastric antral vascular ectasia)
- Aorto-enteric fistula — rare, usually after prior aortic graft surgery
Causes of Lower GI Bleeding
- Diverticular bleeding — the most common cause of significant lower GI bleeding in older adults
- Angiodysplasia (vascular ectasia of the colon)
- Haemorrhoids and anal fissures — common causes of bright-red bleeding per rectum, usually small-volume
- Inflammatory bowel disease — ulcerative colitis, Crohn's disease
- Colorectal cancer and polyps
- Ischaemic colitis
- Infectious colitis
- Post-polypectomy bleeding — after endoscopic polyp removal
- Radiation proctitis
Emergency Management
Initial management of any major GI bleed follows standard resuscitation principles per WSES and BSG guidelines:
- ABC assessment — airway, breathing, circulation
- Two large-bore intravenous cannulas and immediate crystalloid resuscitation
- Send urgent blood for: complete blood count, urea/creatinine/electrolytes, liver function, coagulation, group and cross-match
- Risk stratification using validated scores — Glasgow-Blatchford, Rockall, AIMS65 (upper GI); Oakland score (lower GI)
- Blood product transfusion as needed — restrictive transfusion strategy (Hb threshold ~7–8 g/dL) is recommended for most patients per AABB and BSG
- Reversal of anticoagulation if appropriate (vitamin K, prothrombin complex concentrate, idarucizumab for dabigatran, andexanet for factor Xa inhibitors)
- Initiate PPI infusion for suspected upper GI bleed
- Octreotide/terlipressin and antibiotics for suspected variceal bleed
- Urgent endoscopy — within 24 hours for UGIB; sooner for unstable patients
- Surgical and interventional radiology consultation early in massive or refractory bleeds
Diagnostic Pathway
- Upper GI endoscopy (OGD): first-line for suspected upper GI bleeding; both diagnostic and therapeutic. Best within 24 hours of presentation.
- Colonoscopy: first-line for lower GI bleeding once the patient is stabilised and the bowel prepared.
- CT angiography: for haemodynamically significant ongoing bleeding when the source is unclear. Highly sensitive for active bleeding ≥0.3–0.5 mL/min.
- Capsule endoscopy: for obscure mid-GI (small bowel) bleeding.
- Balloon-assisted enteroscopy (single- or double-balloon): diagnostic and therapeutic for small bowel lesions.
- Tagged red cell scintigraphy: selectively used for slow obscure bleeding.
- Mesenteric angiography: diagnostic and therapeutic (embolisation).
Endoscopic Therapy
Endoscopic haemostasis is the cornerstone of acute GI bleed management. Techniques include:
- Injection therapy — adrenaline (epinephrine) for bleeding ulcers; sclerosants or cyanoacrylate for varices
- Thermal therapy — bipolar coagulation, argon plasma coagulation (APC)
- Mechanical therapy — through-the-scope haemoclips, over-the-scope clips, band ligation (for esophageal varices)
- Topical haemostatic agents — hemospray for diffuse oozing or malignant bleeding
Best practice combines two haemostatic modalities (e.g. adrenaline injection + thermal or clip) for high-risk peptic ulcers per ESGE.
Interventional Radiology
Transcatheter mesenteric angiography with selective embolisation is increasingly used as the second-line treatment after endoscopic failure and as the first-line for actively bleeding diverticular disease or angiodysplasia identified on CT angiography. It avoids the morbidity of emergency surgery, particularly in elderly or comorbid patients.
When Surgery Is Needed
Surgery for GI bleeding is reserved for:
- Failure of endoscopic haemostasis after 2 attempts
- Failure of interventional radiology (embolisation) or where embolisation is not available or feasible
- Haemodynamic instability despite resuscitation
- Bleeding from a lesion that requires definitive surgical resection (e.g. cancer, GIST)
- Perforation accompanying bleeding
- Selected ongoing chronic obscure bleeding from a localised small bowel source
Procedures performed depend on the underlying lesion:
- Bleeding peptic ulcer — under-running of the bleeding vessel, oversewing, vagotomy/pyloroplasty in selected cases, partial gastrectomy rarely needed
- Perforated bleeding ulcer — Graham omental patch ± definitive ulcer surgery
- Bleeding gastric or duodenal malignancy — definitive resection per oncology principles where feasible
- Lower GI bleeding — segmental resection of the bleeding segment after localisation
- Massive undifferentiated lower GI bleed with failed localisation — subtotal colectomy (rarely needed)
Variceal Bleeding
Variceal bleeding in patients with portal hypertension and cirrhosis is a specific high-risk subset requiring joint hepatology and surgical-gastroenterology care. Standard management per Baveno VII / AASLD includes:
- Resuscitation and restrictive transfusion (Hb threshold ~7 g/dL)
- Vasoactive drugs — terlipressin or octreotide for 3–5 days
- Prophylactic antibiotics — reduces mortality
- Urgent (within 12 hours) endoscopic band ligation for esophageal varices; cyanoacrylate injection for gastric varices
- TIPS (Transjugular Intrahepatic Portosystemic Shunt) for early salvage in selected high-risk patients and for refractory bleeding
- Secondary prophylaxis with non-selective beta-blockers and serial band ligation
Secondary Prevention
- After peptic ulcer bleed: PPI therapy, H. pylori eradication, NSAID cessation
- After variceal bleed: non-selective beta-blockers, serial band ligation, treatment of underlying liver disease
- After diverticular bleed: high-fibre diet, NSAID avoidance, colonoscopy follow-up
- After polypectomy or GI cancer: structured oncological and endoscopic surveillance
- Anticoagulation review — re-introduction is individualised based on bleeding source, thrombotic risk and time from bleed
Why Choose Dr A K Bansal for GI Bleeding Management
Dr A K Bansal completed his M.Ch Surgical Gastroenterology at SGPGI Lucknow with All India Rank 1. He is Ex Senior Consultant in the Department of Gastrosciences at Medanta Hospital and currently heads the Department of GI Surgery at Myra City Hospital. His GI bleeding service is delivered as multidisciplinary care with interventional endoscopy, hepatology and interventional radiology.
- Surgical haemostasis for refractory upper and lower GI bleeding
- Definitive surgery for underlying bleeding lesions (ulcer, malignancy, vascular)
- Joint care with hepatology for variceal bleeding
- Multidisciplinary protocols aligned with ESGE, BSG, ACG, WSES and AASLD
- 15+ years of experience and 5000+ surgical procedures
Consult for GI Bleeding Evaluation
If you are actively bleeding, please go to your nearest hospital emergency department immediately. For follow-up or scheduled surgical evaluation after a recent GI bleed, please bring all hospital records, endoscopy and imaging reports.
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Frequently Asked Questions
What is GI bleeding?+
Any bleeding from the digestive tract — esophagus, stomach, intestines, colon, rectum or anus. Classified as upper (above ligament of Treitz) or lower GI bleeding.
What are the symptoms of GI bleeding?+
Upper GI bleed: hematemesis (vomiting blood), melena (black tarry stool). Lower GI bleed: hematochezia (fresh red blood per rectum). Severe bleeding causes dizziness, fainting, fast pulse, pallor. Slow bleeding causes iron-deficiency anaemia.
Is GI bleeding an emergency?+
Yes — visible bleeding or symptoms of shock require emergency evaluation. Early resuscitation, risk stratification and urgent endoscopy within 24 hours are standard of care.
How is GI bleeding diagnosed?+
Upper GI endoscopy for UGIB. Colonoscopy for LGIB once stabilised. CT angiography for ongoing significant bleeding. Capsule endoscopy and balloon enteroscopy for obscure small bowel bleeding.
What is the most common cause of upper GI bleeding?+
Peptic ulcer disease (40–50%). Other major causes: varices, Mallory-Weiss tears, erosive gastritis, Dieulafoy's lesions, upper GI malignancy.
When is surgery needed for GI bleeding?+
For failure of endoscopic haemostasis, failure of embolisation, haemodynamic instability, perforation, and where the underlying lesion (cancer, GIST) needs definitive resection.
What is the mortality of GI bleeding?+
Upper GI bleed: 5–10% in modern series, higher in elderly, comorbid and variceal bleeds. Lower GI bleed: under 5%. Early resuscitation and multidisciplinary care reduce mortality substantially.
