Bleeding During Upper vs. Lower GI Surgery 

September 7, 2023

Despite therapeutic advances in gastroenterology, acute gastrointestinal (GI) bleeding still carries relatively high morbidity and mortality.3 Post-surgery GI bleeds (e.g. post-anastomosis, post-polypectomy, post-sphincterotomy, and post-biopsy) are commonly seen in hospitals and are a risk of both upper and lower GI surgery.2  

Patients with negative angiography (X-ray examination of blood vessels) results are at higher risk for developing bleeding complications following gastrointestinal surgery.3 While angiographic therapies such as embolization or vasopressin can be the first line of defense for post-surgical bleeding, these options do not represent an exhaustive treatment response.3 A major limitation of angiographic therapy is the inability to identify a bleeding locus when it is slow or if bleeding has stopped at the site. The injected contrast material cannot identify that bleeding had occurred in the past; it can only identify an active bleeding site.3 Colonoscopy is another commonly employed technique for GI bleeding diagnosis, however, severe bleeding hinders visualization due to the presence of colonic mucosa. Therefore, colonoscopy is better employed after severe bleeding has abated.4   

Upper gastrointestinal bleeding (UGIB) occurs in the esophagus, stomach, or duodenum while lower gastrointestinal bleeding (LGIB) happens in the small bowel, colon and anorectum and is characterized as bleeding distal to the Ligament of Trietz.1 As reported by Kim et al., the risk for bleeding is much higher with lower gastrointestinal surgery than with upper GI procedures.3 UGIB cases have fallen significantly because helicobacter pylori, a significant cause of bleeding in the stomach, is much better controlled now.1  Another treatment which has lowered upper GI bleeding incidence during GI surgery is proton pump inhibitors (PPIs).5 PPIs inhibit gastric acid to ensure it does not interrupt the clotting activity required to stop bleeding. PPIs can be used before and after endoscopy to prevent UGIB.5  

PPIs haven’t been shown to have any impact on LGIB. Mesenteric angiography is used to assess a severe case of LGIB while a colonoscopy is used for less severe cases. Intervention for lower GI bleeding can take several forms. An epinephrine injection may be administered around the bleeding zones. The bleeding site can be cauterized using a heater probe, laser, or argon plasma coagulator (APC). A current flow is applied using one of these devices. Finally, endoscopic hemostatic clips can be used to address LGIB. The clips carry a reduced risk of damage when compared to cauterizing and have a longer lasting effect when compared to epinephrine injections. There are three types of LGIB commonly encountered in practice – diverticular bleeding, anastomotic bleeding, and post-polypectomy bleeding. All can be treated with the therapies described above.4  

References 

  1. Oakland K. “Changing epidemiology and etiology of upper and lower gastrointestinal bleeding.” Best practice & research Clinical gastroenterology 42 (2019): 101610. 
  1. DiGregorio AM, Alvey H. Gastrointestinal Bleeding. [Updated 2023 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537291/ 
  1. Kim JH et al. “Angiographically negative acute arterial upper and lower gastrointestinal bleeding: incidence, predictive factors, and clinical outcomes.” Korean Journal of Radiology 10.4 (2009): 384-390. 
  1. Whitlow CB. Endoscopic treatment for lower gastrointestinal bleeding. Clin Colon Rectal Surg. 2010 Feb;23(1):31-6. doi: 10.1055/s-0030-1247855. PMID: 21286288; PMCID: PMC2850164. 
  1. Jiang F, Guo CG, Cheung KS, Leung WK. Long-term risk of upper gastrointestinal bleeding after Helicobacter pylori eradication: a population-based cohort study. Aliment Pharmacol Ther. 2021 Nov;54(9):1162-1169. doi: 10.1111/apt.16604. Epub 2021 Sep 16. PMID: 34528716. 
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