Gastrointestinal Bleeding ( GI Bleeding)

Gastrointestinal bleeding includes bleeding from any part of the digestive system between the mouth and the anus, usually as a result of gastritis, ulcers, infections, cancer, anal fissures, hemorrhoids, diverticulitis or some other disorder of the digestive system.

People usually become aware of the bleeding when it is seen in the vomit or in stool. Very small amounts of bleeding may not be visible to naked eye and it is called occult bleeding. It is often detected by stool testing in the laboratory.

Bringing up blood along with vomit is called hematemesis and it is an indication of bleeding in the upper part of the digestive tract. The color of the blood in the vomit is often an indicator of the time and amount of bleeding. Recent bleeding which is continuing still, imparts a bright red tint to the vomit, whereas a brown color precipitate found in vomit indicates a much older episode of bleeding. The discoloration to the blood may have occurred due to the action of digestive acids.

Blood in the stool may be either bright red as in hematochezia or it may have resulted in melena, which is the name given to black, tar-like stools. Usually, hematochezia indicates a recent bleeding in lower part of the digestive tract, but it can also occur due to heavy and rapid bleeding taking place in the upper GI. Melena is generally indicative of bleeding that may have occurred in the upper part of the gastrointestinal tract. The black color of the stool is due to the discoloration of blood, by the action of acids and micro organisms present, as the stomach contents travels through the stomach and the intestines.

If the blood loss is small and limited, people may not have any other symptoms. But significant blood loss may precipitate many symptoms such as low blood pressure, increase in pulse rate, and reduction in urine production. People may feel disoriented, confused or drowsy due to reduced flow of blood to the brain. Their hands and feet, as well as the skin, may feel cold and clammy to touch. People who have ischemia of the heart muscles may develop chest pain or angina due to impaired blood supply to the heart. When there is rapid blood loss, the blood pressure may drop to dangerously low levels, which can lead to shock. Chronic bleeding from the gastrointestinal tract may result in anemia which shows symptoms such as fatigue and dizziness.

Causes

Gastrointestinal bleeding is differentiated into three types, according to the location of its origin. The disorders which may be causing the gastrointestinal bleeding also vary depending on the area of origin.

Upper GI bleeding originates from esophagus and stomach and its usual causes include tears in the esophageal lining due to forceful retching and vomiting, termed Mallory-Weiss syndrome. The bleeding may be seen as traces of blood in the vomit or as coal black stool called melena. Ulcers, varicose veins, and cancer of the esophagus are some other causes. Gastritis, dyspepsia, erosions and ulcers on the walls of stomach and the first part of the small intestine (duodenum) also result in upper GI bleeding.

Lower GI bleeding starts in the large intestine or rectum and it may be seen in the stool as traces of bright red blood or as blackened stool. The usual causes of lower GI bleeding are:

  • inflammatory bowel disease affecting the large intestine
  • bleeding from diverticula in the large intestine
  • polyps in the large intestine
  • ischemic colitis
  • cancer of the colon
  • hemorrhoids in the rectum and anus
  • anorectal fissures
  • inflammation of the bowels due to radiation

Bleeding from small intestine is considered a category on its own, though it is rarer than the other two types. A congenital abnormality known as Meckel’s diverticulum is a common cause of bleeding from the small intestine. Tumors, and abnormalities of the blood vessels in the small intestine, also may result in bleeding.

Certain disorders and conditions make some people more prone to gastrointestinal bleeding. They may also enhance the severity of bleeding. Some such conditions are:

  • Chronic hepatitis
  • Alcohol abuse
  • Hereditary blood clotting disorders
  • Anticoagulant and antiplatelet drugs

Warfarin and heparin, which are anticoagulant drugs used for dissolving clots blood vessels, have an adverse effect on intestinal bleeding. Aspirin and other antiplatelet drugs also cause intestinal bleeding. Some NSAIDs or nonsteroidal anti inflammatory drugs negatively affect the lining of the stomach, exposing it to the action of strong stomach acids which may cause erosion and bleeding.

Evaluation

Gastro intestinal bleeding may be due to a serious condition involving heavy blood loss and other complications or it may be the result of comparatively less significant reasons such as an anal fissure or hemorrhoid. Evaluation by a doctor is necessary to determine the extent and seriousness of the condition.

Warning signs: when gastrointestinal bleeding is accompanied by the warning signs given below, it may need immediate medical attention.

  • Severe, continuous bleeding with more than a cupful of blood loss
  • low blood pressure and fainting
  • Increase in heart rate, to more than 100 beats/ minute
  • Excessive sweating

Those who have the above symptoms should see a doctor without delay as severe complications can develop. Hematemesis, which is blood in the vomit, hematochezia, characterized by bright red blood in the stool or melena, which is black, tarry stools, are all symptoms to be taken seriously.

When a person approaches a doctor with the complaint of bleeding from either the mouth or the anus, the doctor may do a physical examination. The abdominal area, as well as the rectum and anus, are checked, to look for abdominal distension and masses and the presence of internal or external hemorrhoids, anorectal fissures, etc.

The general condition of the patient is also checked for any possible complications. Blood pressure, pulse rate as well as the rate of breathing are all checked. High rate of breathing, fast heart rate, paleness, confusion, cold and clammy skin, reduced urine output etc. are all indicative of hypovolemia or lowered volume of circulating blood. It can lead to very low blood pressure and eventually shock.

The patient’s body may be checked for the presence of purple red spots called petechiae or patches of bruised skin or ecchymoses which indicate bleeding problems. Spider angiomas indicating chronic liver disease; enlargement of spleen and veins on the abdominal wall indicative of portal hypertension, are also checked out.

Details about the nature and quantity of the bleeding and other symptoms such as pain and abdominal discomfort or bloating may help the doctor with the diagnosis. Previous medical history of the patient is also important. If the patient complains of blood in the vomit (hematemesis), doctor may need to know whether traces of blood were present with the first mouthful of vomit or whether it was seen only after several bouts of vomiting. If the blood was present in stool, doctor may need to know whether it was bloody diarrhea or hard stool either mixed with blood or coated in blood. Doctor may be able to assess whether the bleeding has been recent or not, from the color of the blood in the vomit or stool. Details of drugs taken, travels recently undertaken, recent weight loss or signs of anemia, presence of liver disease and habits like alcohol consumption are also taken into account before the doctor decides on further testing to detect the exact problem.

Testing: Unless the doctor can identify the exact cause of bleeding, further testing may be necessary to detect the exact reason and the location of bleeding. For example; bleeding hemorrhoids or anorectal fissures are easily detectable; blood in the vomit after several bouts of vomiting, normally indicates an esophageal tear.

Blood tests are conducted to determine platelet count, prothrombin time and partial thromboplastin time, the abnormal readings of which may indicate bleeding and clotting disorders. Low hemoglobin count may indicate chronic bleeding. Stools are also tested for evidence of infections and worm infestations like hook worms, which may cause intestinal bleeding.

The following tests in addition to lab tests of blood and stool may be conducted to determine gastrointestinal bleeding.

For upper GI bleeding, upper endoscopy is done to detect abnormalities in the esophagus, stomach and duodenum. It can detect esophageal cancers and gastric ulcers which may be responsible for the bleeding. Esophageal tears also can be detected.

A nasogastric tube may be inserted through the nose into the stomach to suction out stomach contents which may show the nature of bleeding. Recent and active bleeding may be shown by bright red color of the contents, while dark brown material resembling coffee grounds indicate bleeding which has spontaneously stopped. The tube can remain inside, till active bleeding stops and the contents in the tube become clear. When nasogastric testing indicates upper GI bleeding, an upper endoscopy is done to determine the exact reason and location of the bleeding.

Upper endoscopy involves the insertion of the endoscope into the esophagus, the stomach and the first portion of the small intestine called duodenum, via the mouth. It is a viewing scope which allows doctors to examine the interiors of upper part of the digestive tract for abnormalities which may be causing the bleeding. It can also help stop the bleeding by cauterizing bleeding ulcers.

For lower GI bleeding, a similar endoscope called sigmoidoscope is inserted via the anus to view the interiors of the anal canal, rectum and the lower part of the large intestine to detect diverticula or hemorrhoids which may be causing the bleeding. Colonoscopy also may be done to view the whole of the large intestine, for the presence of colon cancer.

Enteroscopy is an endoscopic testing of the small intestine. It is usually conducted when both upper GI bleeding and Lower GI bleeding are ruled out through respective endoscopic examinations.

In case of severe, uncontrollable bleeding, angiography may be performed; during which a radioopaque dye is injected into the artery in the affected region and x-rays are taken. In addition to detecting upper GI bleeding, this procedure enables stopping of the bleeding by specific treatments like embolization and injection of a vasoconstrictor to stop the blood supply to the bleeding site. Radionuclide scanning also may be done, in which a special camera picks up red blood cells infused with radioactive markers, to locate the site of bleeding.

In a diagnostic procedure called capsule endoscopy, a capsule containing a miniature camera is swallowed, which captures the internal images while passing down the digestive tract. it is especially useful for the viewing of the small intestines.

Treatment

Stopping the bleeding is the immediate focus of treatment. On many occasions, the bleeding may stop on its own. When the bleeding continues, several treatments are possible to stem it. For upper GI bleeding, electrocautery using an endoscopic device may be used to stop bleeding from peptic ulcers. Injection sclerotherapy and laser therapy are some other endoscopic measures to stop bleeding; but if they are not effective, surgery may be necessary. When injection sclerotherapy is not effective, bleeding from varicose veins in the esophagus and stomach are treated with endoscopic banding, or TIPS shunting, to reduce portal vein hypertension which may be causing the varices.

Lower GI bleeding resulting from angiomas or diverticula can be stopped with electrocauterization, or by coagulation using a heater probe, while conducting a colonoscopy. A wire snare is often used to remove polyps. Sometimes, epinephrine injection is also used to stop bleeding. Severe bleeding which cannot be controlled by the above measures may require stopping of blood supply to the bleeding site by blocking or constricting the blood vessel supplying the area. Embolization in the supply vessel may be achieved by introducing a wire coil, or pieces of gelatin sponge, by angiography. Vasopressin is used to constrict the blood vessel to reduce blood flow to the site of bleeding. Surgical intervention may be necessary if the above mentioned minimally invasive procedures are not effective in stopping the bleeding. Transfusion of platelets or fresh plasma and vitamin K injections may be necessary to stem the bleeding in people who have problems with blood clotting.

Bleeding from hemorrhoids usually does not require emergency measures. If it does not stop, doctor may use rubber bands to cut off blood supply to the hemorrhoids.

Replacement of the fluid lost through bleeding by appropriate means of rehydration is concurrently initiated to avoid complications. If blood loss has been severe, or if it is associated with vomiting or diarrhea, and the patient has developed low blood pressure due to the decreased blood volume, fluids are given intravenously. Occasionally, blood transfusion may be necessary.

Preventing further bleeding is the next step, which usually involves the treatment of underlying disorders. If bleeding is found to be caused by the use of drugs, they are either stopped or replaced by suitable alternatives. Gastritis and peptic ulcers are treated; polyps, diverticula and tumors are surgically removed, if necessary. Hemorrhoids which may cause bleeding in future are destroyed using electrocautery, cryosurgery or rubber band treatment.

Essentials for Older People

Older people may have reduced tolerance to gastrointestinal bleeding; they must get immediate medical attention at the very first sign of bleeding. The usual causes of GI bleeding in older people are diverticulitis, peptic ulcers, abnormal blood vessels and hemorrhoids. Bleeding in older people with no such previous history, may point to cancer of the colon or rectum. Investigative tests are done as soon as possible to determine the cause of bleeding so that appropriate treatment can be initiated without delay and before complications develop.

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Yasser Elnahas

MD, PHD, Professor Of CardioVascular Surgery
Dr. Yasser Elnahas, Is an associate Professor of Cardiovascular Surgery. Dr. Elnahas was trained as a fellow At Texas Heart Institute And Mayo Clinic Foundation.Dr. Elnahas is dedicated to educating the general public about different disease conditions and simplifying the medical knowledge in an easy to understand terminology.

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