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| ==Overview== | | ==[[Gastrointestinal bleeding overview|Overview]]== |
| '''Gastrointestinal bleeding''' or '''gastrointestinal hemorrhage''' describes every form of [[hemorrhage]] (loss of [[blood]]) in the [[gastrointestinal tract]], from the [[pharynx]] to the [[rectum]]. It has diverse causes, and a medical history, as well as [[physical examination]], generally distinguishes between the main forms. The degree of bleeding can range from nearly undetectable to acute, massive, life-threatening bleeding.
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| Initial emphasis is on resuscitation by infusion of [[intravenous therapy|intravenous fluids]] and [[blood transfusion]], treatment with [[proton pump inhibitor]]s and occasionally with [[vasopressin]] analogues and [[tranexamic acid]]. [[Upper endoscopy]] or [[colonoscopy]] are generally considered appropriate to identify the source of bleeding and carry out therapeutic interventions.
| | ==[[Gastrointestinal bleeding historical perspective|Historical Perspective]]== |
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| * '''Hematemesis''' is defined as vomiting blood (fresh blood, clots or "coffee grounds") and is usally due to a bleed in the upper GI tract
| | ==[[Gastrointestinal bleeding classification|Classification]]== |
| * '''Melena''' refers to black, tarry stools and signals an upper GI bleed (blood has had time to be
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| * '''Hematochezia''' refers to red, bloody stools and signals a lower GI bleed or brisk bleeding in the upper GI tract
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| ==Symptoms and signs==
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| Gastrointestinal bleeding can range from microscopic bleeding, where the amount of blood is so small that it can only be detected by laboratory testing (in the form of [[iron deficiency anemia]]), to massive bleeding where pure blood is passed and [[hypovolemia]] and [[Shock (medical)|shock]] may develop, risking [[death]].
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| ==Classification== | | ==[[Gastrointestinal bleeding pathophysiology|Pathophysiology]]== |
| Gastrointestinal bleeding can be roughly divided into two clinical syndromes. | |
| ===Upper gastrointestinal bleeding===
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| {{main|upper gastrointestinal bleeding}}
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| Upper gastrointestinal bleeding is from a source between the [[pharynx]] and the [[Suspensory muscle of the duodenum |ligament of Treitz]]. An upper source is characterised by [[hematemesis]] (vomiting up blood) and [[melena]] (tarry stool containing altered blood).
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| ===Lower gastrointestinal bleeding=== | | ==[[Gastrointestinal bleeding causes|Causes]]== |
| {{main|Lower gastrointestinal bleeding}}
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| Lower gastrointestinal bleeding may be indicated by red blood ''per rectum'', especially in the absence of [[hematemesis]]. Isolated melena may originate from anywhere between the stomach and the proximal colon.
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| == Differential Diagnosis == | | ==[[Gastrointestinal bleeding differential diagnosis|Differentiating Gastrointestinal bleeding from other Diseases]]== |
| === Main Causes ===
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| * [[Diverticula]]
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| * [[Hemorrhoid]] bleeding
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| * Inflammatory colonic diseases
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| * Ischemic colonic diseases
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| * [[Tumor]]s or polyps
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| * Ulcerative diseases
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| === Upper GI Bleeding ===
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| * [[Angiodysplasia]]
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| * [[Anticoagulant]] therapy
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| * [[Arteriovenous malformation]]
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| * [[Carcinoid tumor]]
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| * [[Coagulopathy]]
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| * [[Connective Tissue Disease]]
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| * [[Cytomegalovirus]] (CMV)
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| * [[Duodenal ulcer]]
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| * Duodenal [[varices]]
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| * Duodenum erosion
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| * [[Epistaxis]]
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| * [[Esophageal carcinoma]]
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| * Esophageal ulcer
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| * [[Esophageal varices]]
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| * [[Gastric ulcer]]
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| * [[Gastric carcinoma]]
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| * Gastric varices
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| * GI foreign bodies
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| * [[Helicobacter pylori]]
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| * [[Hemolytic Uremic Syndrome]]
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| * [[Henoch-Schonlein Purpura]]
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| * [[Hereditary Hemorrhagic Telangiectasia]]
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| * [[Herpes]]
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| * [[Ischemic Enteritis]]
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| * [[Karposi's Sarcoma]]
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| * [[Leukemia]]
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| * Lower esophagus erosion
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| * [[Lymphoma]]
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| * [[Mallory-Weiss Tear]]
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| * [[Metestatic tumor]]
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| * [[Osler's Disease]]
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| * [[Polyarteritis Nodosa]]
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| * [[Rheumatoid Arteritis]]
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| * [[Rheumatoid vasculitis]]
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| * Small bowel carcinoma
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| * Stomach erosion
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| * Stomal ulcer
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| * [[Systemic Lupus Erythematosus]]
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| * Upper GI polyp
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| * [[Uremia]]
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| * [[Volvulus]]
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| === Lower GI Bleeding === | | ==[[Gastrointestinal bleeding epidemiology and demographics|Epidemiology and Demographics]]== |
| * [[Amoeba]]
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| * Anal fissure
| | ==[[Gastrointestinal bleeding risk factors|Risk Factors]]== |
| * [[Angiodysplasia]]
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| * [[Angioma]]
| | ==[[Gastrointestinal bleeding natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * Anorectal injuries
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| * [[Aortoenteric Fistula]]
| | ==Diagnosis== |
| * [[Behcet's Syndrome]]
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| * Biopsy (secondary bleeding)
| | [[Gastrointestinal bleeding history and symptoms|History and Symptoms]] | [[Gastrointestinal bleeding physical examination|Physical Examination]] | [[Gastrointestinal bleeding laboratory findings|Laboratory Findings]] | [[Gastrointestinal bleeding x ray|X Ray]] | [[Gastrointestinal bleeding CT|CT]] | [[Gastrointestinal bleeding other imaging findings|Other Imaging Findings]] |
| * [[Campylobacter]]
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| * [[Carcinoid tumors]]
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| * Carcinoma
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| * [[Colitis]]
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| * [[Colon polyp]]s
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| * [[Colorectal carcinoma]]
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| * [[Crohn's Disease]]
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| * [[Diverticulosis]]
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| * [[Familial adenomatous polyposis]]
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| * Fissures
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| * Foreign body
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| * [[Gardner's Syndrome]]
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| * Hemorrhoidal sclerotherapy or ligature
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| * [[Hemorrhoids]]
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| * [[Inflammatory Bowel Disease]]
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| * Invagination
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| * Ischemic colitis
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| * [[Juvenile Polyposis]]
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| * [[Lymphomas]]
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| * Mechanical causes
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| * [[Meckel's Diverticulum]]
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| * [[Mesenteric Infarction]]
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| * [[Peutz-Jegher's Syndrome]]
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| * Polypectomy (secondary bleeding)
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| * Polyps
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| * Postoperative stitching
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| * Proctitis
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| * Prolapse of the rectum
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| * Pseudomembranous Colitis]]
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| * Radiation proctitis
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| * Radiation colitis
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| * Rectal ulcers
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| * [[Salmonella]]
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| * [[Shigella]]
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| * Small bowel tumor
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| * Strangulation
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| * [[Telangiectasia]]
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| * Trauma
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| * Ulcerative colitis
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| * Upper GI bleed
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| * [[Varices]]
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| * Vascular lesions
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| * [[Vasculitis]]
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| * [[Vibrio]] <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
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| ==Treatment== | | ==Treatment== |
| ===Early management===
| | [[Gastrointestinal bleeding medical therapy|Medical Therapy]] | [[Gastrointestinal bleeding surgery|Surgery]] | [[Gastrointestinal bleeding primary prevention|Primary Prevention]] | [[Gastrointestinal bleeding cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Gastrointestinal bleeding future or investigational therapies|Future or Investigational Therapies]] |
| Initial focus in any patient with a form of gastrointestinal hemorrhage is on [[resuscitation]], as any further intervention is precluded by the presence of intravascular depletion or [[Shock (medical)|shock]].
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| * ''Fluid resuscitation:'' [[intravenous fluids]] and [[blood transfusion]] may be administered.
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| * ''Acid suppression'': in an upper GI source, [[proton pump inhibitor]]s reduce [[gastric acid]] production and enhance healing of bleeding lesions.
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| * ''Inhibition of fibrinolysis'': in ongoing bleeding, [[tranexamic acid]] reduces [[fibrinolysis]] and may decrease blood product requirements.
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| * ''Correction of coagulopathy'': if [[coagulation]] parameters (e.g. [[prothrombin time]]) are deranged, [[vitamin K]] or [[fresh frozen plasma]] may need to be administered.
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| * ''Reduction of portal pressure'': if the bleeding is thought to be due to [[esophageal varices]] (a complication of [[cirrhosis]] of the liver), [[vasopressin]] analogues and rarely [[octreotide]] may be administered. Rarely, a [[Sengstaken-Blakemore tube]] may be inserted to mechanically compress varices.
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| * ''Urgent endoscopy'': if the bleeding cannot be managed medically an urgent [[esophagogastroduodenoscopy]] (EGD/OGD) may identify sources of bleeding. This is a high-risk procedure best performed under safe circumstances in the [[intensive care unit]] or [[operating theatre]]s.
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| * ''Surgical intervention'': in extreme cases of bleeding, [[laparotomy]] may be required to identify the bleeding source.
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| ===Endoscopy===
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| After adequate stabilization, [[endoscopy]] ([[upper endoscopy]] and/or [[colonoscopy]]) are used to identify the source of bleeding. Injection, sclerotherapy, electrocoagulation, vascular clipping and biopsy may be performed.
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| Endoscopy is also useful in setting the indication for therapy, e.g. the need for long-term [[proton pump inhibitor]] therapy, presence of [[esophageal varices]], adenomatous polyps and so on.
| | ==Case Studies== |
| | [[Gastrointestinal bleeding case study one|Case #1]] |
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| ==References==
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| {{Reflist|2}}
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| {{Gastroenterology}}
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| [[Category:Surgery]] | | [[Category:Surgery]] |