Gastrointestinal Bleeding – Types, Causes, Treatment

2

Gastrointestinal Bleeding

Gastrointestinal bleeding is a symptom of many digestive system disorders, including reflux, ulcers and cancer. It can occur in any part of the digestive system (GI tract), which runs from the mouth to the anus. Bleeding can be mild and ongoing or come on suddenly and be life-threatening.

Gastrointestinal bleeding is when there is blood loss from any of the several organs included in your digestive system. It can occur from any part of the GI tract that runs from your mouth to your anus.

Upper GI bleeds stem from issues with your:

Small Bowel bleeds stem from issues with your:

Lower GI bleeds stem from issues with your:

 Types

Gastrointestinal (GI) bleeding can originate anywhere from the mouth to the anus and can be overt or occult. The manifestations depend on the location and rate of bleeding. (See also Varices and Vascular Gastrointestinal Lesions.)

Hematemesis is vomiting of red blood and indicates upper GI bleeding, usually from a peptic ulcer, vascular lesion, or varix. Coffee-ground emesis is vomiting of dark brown, granular material that resembles coffee grounds. It results from upper GI bleeding that has slowed or stopped, with conversion of red hemoglobin to brown hematin by gastric acid.

Hematochezia is the passage of gross blood from the rectum and usually indicates lower GI bleeding but may result from vigorous upper GI bleeding with rapid transit of blood through the intestines.

Melena is black, tarry stool and typically indicates upper GI bleeding, but bleeding from a source in the small bowel or right colon may also be the cause. About 100 to 200 mL of blood in the upper GI tract is required to cause melena, which may persist for several days after bleeding has ceased. Black stool that does not contain occult blood may result from ingestion of iron, bismuth, or various foods and should not be mistaken for melena.

Chronic occult bleeding can occur from anywhere in the GI tract and is detectable by chemical testing of a stool specimen.

Acute, severe bleeding also can occur from anywhere in the GI tract. Patients may present with signs of shock. Patients with underlying ischemic heart disease may develop angina or myocardial infarction because of coronary hypoperfusion.

GI bleeding in patients with underlying liver disease may precipitate portosystemic encephalopathy or hepatorenal syndrome (kidney failure secondary to liver failure).

Common Causes

Upper GI tract

Duodenal ulcer (20–30%) Gastric or duodenal erosions (20–30%) Varices (15–20%) Gastric ulcer (10–20%) Mallory-Weiss tear (5–10%) Erosive esophagitis (5–10%) Angioma (5–10%) Arteriovenous malformations (< 5%) Gastrointestinal stromal tumorsHemobilia

Lower GI tract (percentages vary with the age group sampled)

Anal fissures Angiodysplasia (vascular ectasia) Colitis: Radiation, ischemic, infectious Colonic carcinoma Colonic polyps Diverticular disease Inflammatory bowel disease: Ulcerative proctitis/colitis, Crohn disease Internal hemorrhoids

Complications

A gastrointestinal bleed can cause:

Diagnosis

Your doctor will take a medical history, including a history of previous bleeding, conduct a physical exam and possibly order tests. Tests might include:

Treatment

Hematemesis, hematochezia, or melena should be considered an emergency. Admission to an intensive care unit or other monitored setting, with consultation by both a gastroenterologist and a surgeon, is recommended for all patients with severe GI bleeding. General treatment is directed at maintenance of the airway and restoration of circulating volume. Hemostasis and other treatment depend on the cause of the bleeding.

Airway

A major cause of morbidity and mortality in patients with active upper GI bleeding is aspiration of blood with subsequent respiratory compromise. To prevent these problems, endotracheal intubation should be considered in patients who have inadequate gag reflexes or are obtunded or unconscious—particularly if they will be undergoing upper endoscopy.

Fluid resuscitation and blood product transfusion

Intravenous access should be obtained immediately. Short, large-bore (eg, 14- to 16-gauge) IV catheters in the antecubital veins are preferable to a central venous catheter unless a large (8.5 Fr) sheath is used. IV fluids are initiated immediately, as for any patient with hypovolemia or hemorrhagic shock ( see Intravenous Fluid Resuscitation). Healthy adults are given normal saline IV in 500- to 1000-mL aliquots until signs of hypovolemia remit—up to a maximum of 2 L (for children, 20 mL/kg, that may be repeated once).

Patients requiring further resuscitation should receive transfusion with packed RBCs. Transfusions continue until intravascular volume is restored and then are given as needed to replace ongoing blood loss. Transfusions in older patients or those with coronary artery disease may be stopped when hematocrit is stable at 30 unless the patient is symptomatic. Younger patients or those with chronic bleeding are usually not transfused unless hematocrit is < 23 or they have symptoms such as dyspnea or coronary ischemia.

Platelet count should be monitored closely; platelet transfusion may be required with severe bleeding. Patients who are taking antiplatelet drugs (eg, clopidogrel, aspirin) have platelet dysfunction, often resulting in increased bleeding. Platelet transfusion should be considered when patients taking these drugs have severe ongoing bleeding, although a residual circulating drug (particularly clopidogrel) may inactivate transfused platelets. If patients are taking an antiplatelet drug or an anticoagulant for a recent cardiovascular indication, a cardiologist should be consulted, if possible, prior to stopping the drug, reversing the drug, or giving a platelet transfusion.

If a significant blood transfusion is required, fresh frozen plasma and platelets also should be transfused along with packed RBCs according to the institution’s massive transfusion protocols. If the patient has a coagulopathy, correction with fresh frozen plasma or prothrombin complex concentrate should be considered.

Drugs

An IV proton pump inhibitor (PPI) should be started in cases of possible upper GI bleeding.

Octreotide (a synthetic analog of somatostatin) is used in patients with suspected variceal bleeding. Octreotide is given as a 50-mcg IV bolus, followed by continuous infusion of 50 mcg/hour.

Hemostasis

GI bleeding stops spontaneously in about 80% of patients. The remaining patients require some type of intervention. Specific therapy depends on the bleeding site. Early intervention to control bleeding is important to minimize mortality, particularly in elderly patients.

For peptic ulcer, ongoing bleeding or rebleeding is treated with endoscopic coagulation (with bipolar electrocoagulation, injection sclerotherapy, heater probes, or clips; 1). Nonbleeding vessels that are visible within an ulcer crater are also treated. If endoscopy does not stop the bleeding, angiographic embolization of the bleeding vessel may be attempted, or surgery is required to oversew the bleeding site. Hemostatic powder may be used as a temporizing agent, especially for peptic ulcers or cancer. If the patient has been treated medically for peptic ulcer disease but has recurrent bleeding, surgeons do acid-reduction surgery at the same time.

Active variceal bleeding can be treated with endoscopic banding, injection sclerotherapy, or a transjugular intrahepatic portosystemic shunting (TIPS) procedure (1).

Severe, ongoing lower GI bleeding caused by diverticula or angiomas can sometimes be controlled colonoscopically by clips, electrocautery, coagulation with a heater probe, or injection with dilute epinephrine (see ACG practice guidelines on management of patients with acute lower GI bleeding). Polyps can be removed by snare or cautery. If these methods are ineffective or unfeasible, angiography with embolization or vasopressin infusion may be successful. However, because collateral blood flow to the bowel is limited, angiographic techniques have a significant risk of bowel ischemia or infarction unless super-selective catheterization techniques are used. In most series, the rate of ischemic complications is < 5%. Vasopressin infusion has about an 80% success rate for stopping bleeding, but bleeding recurs in about 50% of patients. Also, there is a risk of hypertension and coronary ischemia. Furthermore, angiography can be used to localize the source of bleeding more accurately.

Surgery may be done in patients with continued lower GI bleeding (requiring > 6 units transfusion), but localization of the bleeding site is very important. If the bleeding site cannot be localized, subtotal colectomy is recommended. Blind hemicolectomy (with no preoperative identification of the bleeding site) carries a much higher mortality risk than does directed segmental resection and may not remove the bleeding site; the rebleeding rate is 40%. However, assessment must be expeditious so that surgery is not unnecessarily delayed. In patients who have received > 10 units of packed RBCs, the mortality rate is about 30%.

Acute or chronic bleeding of internal hemorrhoids stops spontaneously in most cases. Patients with refractory bleeding are treated via anoscopy with rubber band ligation, injection, coagulation, or surgery.

What you can do

When you make the appointment, ask if there’s anything you need to do in advance, such as fasting before a specific test. Make a list of:

Take a family member or friend along, if possible, to help you remember the information you’re given.

For gastrointestinal bleeding, basic questions to ask your doctor include: