Gastrointestinal bleeding: Difference between revisions
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{{ | {{Gastrointestinal bleeding}} | ||
{{CMG}} ; {{AE}} {{ADG}}<br> | |||
{{SK}} 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== | ==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 bleeding|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. | ||
Gastrointestinal bleeding | *'''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== | |||
{| class="wikitable" | |||
!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 cancer|Esophageal tumors]] | |||
*[[Esophagitis]] | |||
*Gastric erosions/[[gastropathy]] | |||
*Dieulafoy lesions | |||
*[[Gastric antral vascular ectasia]] | |||
|- | |||
|Lower gastrointestinal bleeding | |||
| | |||
| | |||
* [[Diverticulosis]] | |||
* [[Angiodysplasia|Vascular ectasias]] | |||
* [[Ischemic colitis]] | |||
* [[Colorectal cancer|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== | ==Classification== | ||
Gastrointestinal bleeding | The following flow chart elobarates the classification of gastrointestinal bleeding: | ||
=== | {{familytree/start}} | ||
{{ | {{familytree | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | |A01=Gastrointestinal bleeding}} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | }} | |||
{{familytree | | | | | | | | | |,|-|-|-|-|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|.| }} | |||
{{familytree | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | A02 | | | A01=Upper GI bleeding|A02=Lower GI bleeding}} | |||
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | |!| }} | |||
{{familytree | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | B02 | | | |B01=Based on blood loss|B02=Based on severity of blood loss}} | |||
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| | | | | | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| | }} | |||
{{familytree | | C01 | | | | | C02 | | | | | C03 | | | | | | | | C04 | | | | | C05 | | | | | C06 | | | C01=Overt|C02=Occult|C03=Obscure|C04=Severe|C05=Moderate|C06=Occult}} | |||
{{familytree | | |!| | | | | | |!| | | | | | |!| | | | | | | | | |!| | | | | | |!| | | | | | |!| | | }} | |||
{{familytree | | D01 | | | | | D02 | | | | | D03 | | | | | | | | D04 | | | | | D05 | | | | | D06 |D01=[[Hematemesis]]<br>Coffee-ground emesis<br>[[Melena]]<br>|D02=Microscopic hemorrhage<br>Heme-occult positive stools|D03=Source is not identified|D04=[[Hematochezia]]|D05=[[Hematochezia]]|D06=Microscopic hemorrhage<br>Heme-occult positive stools}} | |||
{{familytree/end}} | |||
== | ==Differentiating Gastrointestinal Bleeding from other Diseases== | ||
== | {| align="center" | ||
=== | |- | ||
* [[ | | | ||
* [[ | {| style="border: 0px; font-size: 90%; margin: 3px;" align="center" | ||
* | ! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Disease | ||
* | | colspan="13" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Clinical manifestations''' | ||
* [[ | ! colspan="2" rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Diagnosis | ||
* | ! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Comments | ||
=== Upper GI | |- | ||
* [[ | | colspan="9" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" |'''Symptoms''' | ||
* [[ | ! colspan="4" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Signs | ||
* [[ | |- | ||
* [[ | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Abdominal Pain | ||
* [[ | ! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Fever | ||
* [[ | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Rigors and chills | ||
* [[ | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Nausea or vomiting | ||
* [[ | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Jaundice | ||
* | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Constipation | ||
* | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Diarrhea | ||
* [[ | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Weight loss | ||
* [[ | ! style="background:#4479BA; color: #FFFFFF;" align="center" |GI bleeding | ||
* | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Hypo- | ||
* [[ | tension | ||
* [[ | ! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Guarding | ||
* [[ | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Rebound Tenderness | ||
* | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Bowel sounds | ||
* | ! colspan="1" rowspan="1" style="background:#4479BA; color: #FFFFFF;" align="center" | Lab Findings | ||
* [[ | ! style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging | ||
* [[ | |- | ||
* [[ | | colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" | [[Peptic Ulcer Disease|Peptic ulcer disease]] | ||
* [[ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse | ||
* [[ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
* [[ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
* [[ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | <nowiki>+</nowiki> | ||
* [[ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
* | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
* [[ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
* [[ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | <nowiki>+</nowiki> | ||
* [[ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | | ||
* [[ | * Gastric ulcer- [[melena]] and [[hematemesis]] | ||
* [[ | * Duodenal ulcer- [[melena]] and [[hematochezia]] | ||
* [[ | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present if perforated | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present if perforated | |||
* | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present if perforated | ||
* | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
* | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
* [[ | * Ascitic fluid | ||
* | ** [[LDH]] > serum [[LDH]] | ||
* [[ | ** Glucose < 50mg/dl | ||
* [[ | ** Total protein > 1g/dl | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Air under [[diaphragm]] in upright [[CXR]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Upper GI [[endoscopy]] for diagnosis | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gastritis|Gastritis]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[Epigastric]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | <nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present in chronic gastritis | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[H.pylori infection diagnostic tests]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Endoscopy]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[H.pylori gastritis guideline recommendation]] | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Gastrointestinal perforation]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>-</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive/hypoactive | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* WBC> 10,000 | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Air under [[diaphragm]] in upright [[CXR]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Hamman's sign]] | |||
|- | |||
| colspan="1" rowspan="1" style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Diverticulitis|Acute diverticulitis]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |LLQ | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present in perforated diverticulitis | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hypoactive | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Leukocytosis]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* CT scan | |||
* Ultrasound | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* History of [[constipation]] | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Inflammatory bowel disease]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Normal or hyperactive | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Anti-neutrophil cytoplasmic antibody]] ([[P-ANCA]]) in [[Ulcerative colitis]] | |||
* [[Anti saccharomyces cerevisiae antibodies]] (ASCA) in [[Crohn's disease]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[String sign]] on [[abdominal x-ray]] in [[Crohn's disease]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
Extra intestinal findings: | |||
* [[Uveitis]] | |||
* [[Arthritis]] | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Infective colitis]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present in fulminant colitis | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Stool culture]] and studies | |||
* Shiga toxin in bloody diarrhea | |||
* [[PCR]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT scan | |||
* Bowel wall thickening | |||
* Edema | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Colon carcinoma | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Diffuse/localized | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Normal or hyperactive if obstruction present | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* CBC | |||
* Carcinoembryonic antigen (CEA) | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Colonoscopy | |||
* Flexible sigmoidoscopy | |||
* Barium enema | |||
* CT colonography | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Budd-Chiari syndrome|Budd-Chiari syndrome]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present in liver failure leading to [[varices]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
*Elevated [[Aspartate aminotransferase|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|bilirubin levels]], decreased [[Albumin|serum albumin level]]. | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center" | |||
|- | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Findings on [[CT scan]] suggestive of Budd-Chiari syndrome include: | |||
*Early enhancement of the [[caudate lobe]] and [[central liver]] around the [[Inferior vena cavae|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 [[Liver|peripheral liver]] in affected areas | |||
|} | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Ascitic tap|Ascitic fluid examination]] shows: | |||
*[[Total protein]] more than 2.5 g per deciliter | |||
*[[White blood cells]] are usually less than 500/μL. | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Hemochromatosis]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present in cirrhotic patients | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* >60% TS | |||
* >240 μg/L SF | |||
* Raised LFT <br>Hyperglycemia | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Ultrasound shows evidence of cirrhosis | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Extra intestinal findings: | |||
* Hyperpigmentation | |||
* Diabetes mellitus | |||
* Arthralgia | |||
* Impotence in males | |||
* Cardiomyopathy | |||
* Atherosclerosis | |||
* Hypopituitarism | |||
* Hypothyroidism | |||
* Extrahepatic cancer | |||
* Prone to specific infections | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Cirrhosis|Cirrhosis]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |[[RUQ]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Hypoalbuminemia]] | |||
* Prolonged PT | |||
* Abnormal LFTs | |||
* [[Hyponatremia]] | |||
* [[Thrombocytopenia]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |US | |||
* Nodular, shrunken liver | |||
* [[Ascites]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Stigmata of liver disease | |||
* Cruveilhier- Baumgarten murmur | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Mesenteric ischemia]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Periumbilical | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Present if bowel becomes gangrenous | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present if bowel becomes gangrenous | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present if bowel becomes gangrenous | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive to absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Leukocytosis]] and [[lactic acidosis]] | |||
* [[Amylase]] levels | |||
* [[D-dimer]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |CT angiography | |||
* SMA or SMV thrombosis | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Also known as abdominal angina that worsens with eating | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ischemic colitis|Acute ischemic colitis]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Diffuse | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive then absent | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Leukocytosis]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |[[Abdominal x-ray]] | |||
* Distension and pneumatosis | |||
CT scan | |||
* Double halo appearance, thumbprinting | |||
* Thickening of bowel | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* May lead to shock | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Ruptured abdominal aortic aneurysm]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Diffuse | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* [[Fibrinogen]] | |||
* [[D-dimer]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Focused Assessment with Sonography in Trauma (FAST) | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* Unstable hemodynamics | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Intra-abdominal or [[retroperitoneal hemorrhage]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Diffuse | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* ↓ Hb | |||
* ↓ Hct | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* CT scan | |||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | |||
* History of [[trauma]] | |||
|- | |||
|} | |||
|} | |||
<span style="font-size:85%">'''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]]</span> | |||
=== | ==Symptomatic approach to the differential of Upper gastrointestinal bleeding== | ||
<small> | |||
{{familytree/start |summary=Sample 1}} | |||
{{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | A01=Gastrointestinal Bleeding}} | |||
{{familytree | | | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | C01 | | | | | | | | C02 | | | | | | | | | | | | | |C01=Blood in [[Vomiting]]|C02=Black tarry stools|C03=Blood in stools}} | |||
{{familytree | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | |`|-|-|-| D01 |-|-|-|'| | | | | | | | | | | | | | | | D01=[[Abdominal pain]] |D02=[[Abdominal pain]]}} | |||
{{familytree | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | E01 | | | | | | | | | | | | | E02 | | | | | | | | | | | | | | | |E01='''Yes'''|E02='''No'''|}} | |||
{{familytree | | | | | | | |!| | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | F01 | | | | | | | | | | | | | F02 | | | | | | | | | | | | | | | | | |F01=[[Weight loss]]|F02=[[Dysphagia]]}} | |||
{{familytree | | | |,|-|-|-|^|-|-|-|-|-|.| | | | |,|-|-|-|^|-|-|-|-|.| | | | | | | | | |}} | |||
{{familytree | | | G01 | | | | | | | | G02 | | | G03 | | | | | | | G04 | | | | | | | | | |G01='''Yes'''|G02='''No'''|G03='''No'''|G04='''Yes'''}} | |||
{{familytree | | | |!| | | | | | | | | |!| | | | |!| | | | | | | | |!| | | | | | | | | |}} | |||
{{familytree | | | |!| | | | | | | | | |!| | | | H03 | | | | | | | H04 | | | | | | | | | |H03=[[Mallory-Weiss syndrome]]<br>[[Boerhaave syndrome]]|H04=[[Weight loss]]}} | |||
{{familytree | | | |!| | | | | | | | | H02 | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | |H02=[[Dyspepsia]]}} | |||
{{familytree | | | A01 | | | | |,|-|-|-|^|-|-|-|.| | | | | I03 | | | | | | I04 | | | | | |A01='''[[Gastric cancer]]'''<br>'''[[Gastric ulcer]]'''|I03=Yes|I04=No|}} | |||
{{familytree | | | | | | | | | I01 | | | | | | I02 | | | | |!| | | | | | | |!| | | | | | |I01=Yes|I02=No}} | |||
{{familytree | | | | | | | | | |!| | | | | | | |!| | | | | J03 | | | | | | J04 | | | | | |J03=[[Esophageal carcinoma]]|J04=Immune status}} | |||
{{familytree | | | | | | | | | J01 | | | | | | J02 | | | | | | | | |,|-|-|-|^|-|-|.| | | | |J01=[[Duodenal ulcer]]|J02=[[Varices]]}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | K01 | | | | | K02 | | |K01=Immunocomprimised|K02=Immunocompetent|}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | |!| | | |}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | L01 | | | | | L02 | | L01=Infectious [[esophagitis]]|L02=Pill induced [[esophagitis]]}} | |||
{{familytree/end}} | |||
</small> | |||
== | ==Symptomatic approach to differential of lower gastrointestinal bleeding== | ||
=== | <small> | ||
<div style="width: 55%;"> | |||
{{familytree/start |summa|ry=Sample 1}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | A01=Blood in stools}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | M01 |M01=[[Abdominal pain]] }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | |,|-|-|-|-|^|-|-|-|.| }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | N01 | | | | | | | N02 | | |N01=Yes|N02=No}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |!| | | |}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | O01 | | | | | | | O02 | |O01=[[Fever]]|O02=Rectal pain}} | |||
{{familytree | | | | | | | | | | | | | | | |,|-|-|-|-|-|-|-|-|-|-|-|-|^|-|-|-|-|.| | | |!| | }} | |||
{{familytree | | | | | | | | | | | | | | | P01 | | | | | | | | | | | | | | | | P02 | | |!|P01=Yes|P02=No}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | |!| | }} | |||
{{familytree | | | | | | | | | | | | | | | Q01 | | | | | | | | | | | | | | | | Q02 | | |`|-|-|.|Q01=H/O of [[constipation]]|Q02=H/O of [[constipation]]}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |,|-|-|-|^|-|-|-|.| | |!||}} | |||
{{familytree | | | | | | | | | | |,|-|-|-|-|^|-|-|-|.| | | | | | | | | B01 | | | | | | B02 | |!|B01=No|B02=Yes|}} | |||
{{familytree | | | | | | | | | | R01 | | | | | | | R02 | | | | | | | | |!| | | | | | | |!| | |!| R01=No|R02=Yes}} | |||
{{familytree | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | C01 | | | | | | C02 | |!|C01=[[Weight loss]]|C02=[[Diverticulosis]]}} | |||
{{familytree | | | | | | | | | | S01 | | | | | | | S02 | | | | |,|-|-|-|^|-|-|-|.| | | | | | |!|S01=Hemodynamic status|S02=[[Diverticulitis]]| }} | |||
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | | | D01 | | | | | | D02 | | | | | |!|D01=No|D02=Yes}} | |||
{{familytree | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | |!| | | | | | | |!| | | | | | |!|}} | |||
{{familytree | | | | | | T01 | | | | | | T02 | | | | | | | | | E01 | | | | | | E02 | | | | | |!|T01=Stable|T02=Unstable|E01=[[Polyps]]|E02=[[Colon cancer]]}} | |||
{{familytree | | | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | |!|}} | |||
{{familytree | | | | | | |!| | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |,|-|-|-|'|A01=[[Ischemic colitis]]}} | |||
{{familytree | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | |B01=[[Stool culture]]}} | |||
{{familytree | | |,|-|-|-|^|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | |,|-|-|-|^|-|-|-|-|.|}} | |||
{{familytree | | |!| | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |!| |}} | |||
{{familytree | | X03 | | | | | | | X04 | | | | | | | | | | | | | | | | | | | X01 | | | | | | | X02 |X01=No|X02=Yes|X03=Positive|X04=Negative}} | |||
{{familytree | | |!| | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |!| |}} | |||
{{familytree | | U03 | | | | | | | U04 | | | | | | | | | | | | | | | | | | | U01 | | | | | | | U02 |U01=Weight Loss|U02=[[Anal fissure]]<br> External [[Hemorrhoids]]|U03=[[Infectious colitis]]|U04=[[Inflammatory bowel disease]]}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |,|-|-|-|-|^|-|-|-|-|.| |}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | C03 | | | | | | | | C04 |C03=Yes|C04=No|}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| | }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | D01 | | | | | | | | D02 |D01=Rectal cancer<br>[[Colon cancer]]|D02=[[Angiodysplasia]]<br>Polyps }} | |||
{{familytree/end}} | |||
</div> | |||
</small> | |||
[[Category:Surgery]] | [[Category:Surgery]] | ||
[[Category:Gastroenterology]] | [[Category:Gastroenterology]] | ||
[[Category: | [[Category:Emergency medicine]] | ||
[[fr:Hémorragie digestive]] | [[fr:Hémorragie digestive]] | ||
[[pt:Sangramento gastrointestinal]] | [[pt:Sangramento gastrointestinal]] | ||
{{WikiDoc Help Menu}} | {{WikiDoc Help Menu}} | ||
{{WikiDoc Sources}} | {{WikiDoc Sources}} |
Latest revision as of 02:25, 23 December 2017
Gastrointestinal bleeding Main page |
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 |
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Upper gastrointestinal bleeding |
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Lower gastrointestinal bleeding |
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
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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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||