Gastrointestinal bleeding

Gastrointestinal bleeding Main page
Patient Information
Overview
Causes
Classification Upper gastrointestinal bleeding Lower gastrointestinal bleeding
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Synonyms and keywords: Blood loss from GI tract; bloody stool; blood in feces; PR bleeding; gastrointestinal hemorrhage; gastrointestinal hemorrhage; GI bleeding; bright red blood per rectum; BRBPR.

Overview

Gastrointestinal (GI) bleeding is defined as bleeding from any part of GI tract starting from mouth to anus. It can also be called as gastrointestinal hemorrhage. Based on the origin of bleeding it can be classified into upper gastrointestinal bleeding and lower gastrointestinal bleeding. Upper gastrointestinal bleeding (UGIB) is defined as bleeding from the gastrointestinal tract that originates proximal to the ligament of Treitz. Lower gastrointestinal bleeding is defined as blood loss originating distal to the ligament of Treitz. The most common causes of UGIB are peptic ulcer disease and esophageal varice while diverticulosis is the most commonly responsible for lower gastrointestinal bleeding. Clinical presentation includes overt bleeding from the gastrointestinal tract, rapid or slow, either manifested by hematemesis of fresh (blood-streaked to frankly bloody), old ('coffee ground') vomitus, melena and or as frank blood per rectum.

Common risk factors in the development of GI bleeding include advancing age, previous history of gastrointestinal bleed, chronic constipation, hematologic disorders, anticoagulants medications, non-steroidal anti-inflammatory drugs. It is essential to distinguish between lower gastrointestinal bleeding and brisk upper gastrointestinal bleeding as they can present with similar symptoms. Patients with severe bleeding or hemodynamic disturbance require hospitalization and urgent investigation. Treatment depends on the cause and the severity of the bleeding.

Types of bleeding

Bleeding from the gastrointestinal tract can be of the following types:

• Haematemesis: Vomiting fresh red blood.
• Coffee ground emesis: Vomiting of altered black blood.
• Melaena: Passage of black tarry stools.
• Haemochezia: Passage of red blood per rectum (usually due to bleeding from the lower gastrointestinal tract but occasionally can be due to massive upper gastrointestinal bleeding).
• Rebleeding: Defined as fresh haematemesis and/or melaena associated with the development of shock (pulse greater than 100 beats/min, systolic pressure less than 100 mm Hg), a fall in CVP greater than 5 mm Hg, or a reduction in haemoglobin concentration greater than 20 g/l over 24 hours. Rebleeding should always be confirmed by endoscopy.

Causes

Gastrointestinal bleeding	Lethal causes	Common causes	Less common causes
Upper gastrointestinal bleeding	Anthrax Ebola virus	Duodenal ulcer Esophagitis Esophageal varices Gastric tumors Gastric ulcer Gastritis Mallory-Weiss syndrome Peptic ulcer	Gastric cancer Esophageal tumors Esophagitis Gastric erosions/gastropathy Dieulafoy lesions Gastric antral vascular ectasia
Lower gastrointestinal bleeding		Diverticulosis Vascular ectasias Ischemic colitis Colorectal malignancy Hemorrhoids Anal fissures Crohn's disease Ulcerative colitis Infectious colitis Colonic polyps Radiation proctitis Rectal varices Stercoral ulceration Meckel diverticulum Intussusception  Henoch-Schönlein purpura (HSP)

Classification

The following flow chart elobarates the classification of gastrointestinal bleeding:

Gastrointestinal bleeding

Upper GI bleeding

Lower GI bleeding

Based on blood loss

Based on severity of blood loss

Overt

Occult

Obscure

Severe

Moderate

Occult

Hematemesis Coffee-ground emesis Melena

Microscopic hemorrhage Heme-occult positive stools

Source is not identified

Hematochezia

Hematochezia

Microscopic hemorrhage Heme-occult positive stools

Differentiating Gastrointestinal Bleeding from other Diseases

Disease Clinical manifestations Diagnosis Comments Symptoms Signs Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo- tension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Peptic ulcer disease Diffuse ± − + − − − + Gastric ulcer- melena and hematemesis Duodenal ulcer- melena and hematochezia Present if perforated Present if perforated Present if perforated N Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis Gastritis Epigastric ± − + − − − Present in chronic gastritis + − − − N H.pylori infection diagnostic tests Endoscopy H.pylori gastritis guideline recommendation Gastrointestinal perforation Diffuse + ± - ± − − − + + + ± Hyperactive/hypoactive WBC> 10,000 Air under diaphragm in upright CXR Hamman's sign Acute diverticulitis LLQ + ± + − + ± − + Present in perforated diverticulitis + + Hypoactive Leukocytosis CT scan Ultrasound History of constipation Inflammatory bowel disease Diffuse ± − − ± − + + + − − − Normal or hyperactive Anti-neutrophil cytoplasmic antibody (P-ANCA) in Ulcerative colitis Anti saccharomyces cerevisiae antibodies (ASCA) in Crohn's disease String sign on abdominal x-ray in Crohn's disease Extra intestinal findings: Uveitis Arthritis Infective colitis Diffuse + − ± − − + − + Present in fulminant colitis ± ± Hyperactive Stool culture and studies Shiga toxin in bloody diarrhea PCR CT scan Bowel wall thickening Edema Colon carcinoma Diffuse/localized − − − − ± ± + + ± − − Normal or hyperactive if obstruction present CBC Carcinoembryonic antigen (CEA) Colonoscopy Flexible sigmoidoscopy Barium enema CT colonography  PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction Budd-Chiari syndrome RUQ ± − − ± − − − Present in liver failure leading to varices − − − N Elevated serum aspartate aminotransferase and alanine aminotransferase levels may be more than five times the upper limit of the normal range. Elevated serum alkaline phosphatase and bilirubin levels, decreased serum albumin level. Findings on CT scan suggestive of Budd-Chiari syndrome include: Early enhancement of the caudate lobe and central liver around the inferior vena cava Delayed enhancement of the peripheral liver with accompanying central low density (flip-flop appearance) Peripheral zones of the liver show reversed portal venous blood flow In the chronic phase, there is caudate lobe enlargement and atrophy of the peripheral liver in affected areas Ascitic fluid examination shows: Total protein more than 2.5 g per deciliter White blood cells are usually less than 500/μL. Hemochromatosis RUQ − − − − − − − Present in cirrhotic patients − − − N >60% TS >240 μg/L SF Raised LFT Hyperglycemia Ultrasound shows evidence of cirrhosis Extra intestinal findings: Hyperpigmentation Diabetes mellitus Arthralgia Impotence in males Cardiomyopathy Atherosclerosis Hypopituitarism Hypothyroidism Extrahepatic cancer Prone to specific infections Cirrhosis RUQ − − − + − − + + + − − N Hypoalbuminemia Prolonged PT Abnormal LFTs Hyponatremia Thrombocytopenia US Nodular, shrunken liver Ascites Stigmata of liver disease Cruveilhier- Baumgarten murmur Mesenteric ischemia Periumbilical Present if bowel becomes gangrenous − + − − + + + Present if bowel becomes gangrenous Present if bowel becomes gangrenous − Hyperactive to absent Leukocytosis and lactic acidosis Amylase levels D-dimer CT angiography SMA or SMV thrombosis Also known as abdominal angina that worsens with eating Acute ischemic colitis Diffuse + ± + − − + + + + + + Hyperactive then absent Leukocytosis Abdominal x-ray Distension and pneumatosis CT scan Double halo appearance, thumbprinting Thickening of bowel May lead to shock Ruptured abdominal aortic aneurysm Diffuse ± − + − − − + + + − − N Fibrinogen D-dimer Focused Assessment with Sonography in Trauma (FAST)  Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage Diffuse ± − ± − − − − + + − − N ↓ Hb ↓ Hct CT scan History of trauma

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Symptomatic approach to the differential of Upper gastrointestinal bleeding

Gastrointestinal Bleeding

Blood in Vomiting

Black tarry stools

Abdominal pain

Yes

No

Weight loss

Dysphagia

Yes

No

No

Yes

Mallory-Weiss syndrome Boerhaave syndrome

Weight loss

Dyspepsia

Gastric cancer Gastric ulcer

Yes

No

Yes

No

Esophageal carcinoma

Immune status

Duodenal ulcer

Varices

Immunocomprimised

Immunocompetent

Infectious esophagitis

Pill induced esophagitis

Symptomatic approach to differential of lower gastrointestinal bleeding

Blood in stools

Abdominal pain

Yes

No

Fever

Rectal pain

Yes

No

H/O of constipation

H/O of constipation

No

Yes

No

Yes

Weight loss

Diverticulosis

Hemodynamic status

Diverticulitis

No

Yes

Stable

Unstable

Polyps

Colon cancer

Ischemic colitis

Stool culture

Positive

Negative

No

Yes

Infectious colitis

Inflammatory bowel disease

Weight Loss

Anal fissure External Hemorrhoids

Yes

No

Rectal cancer Colon cancer

Angiodysplasia Polyps