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Gastrointestinal Bleeding

by Norton J. Greenberger, MD

Bleeding may occur anywhere along the digestive (gastrointestinal [GI]) tract, from the mouth to the anus. Blood may be easily seen by the naked eye (overt) or may be present in amounts too small to be visible (occult). Occult bleeding is detected only by chemical testing of a stool specimen.

Blood may be visible in vomit (hematemesis), which indicates the bleeding is coming from the upper GI tract, usually from the stomach or the first part of the small intestine. When blood is vomited, it may be bright red if bleeding is brisk and ongoing. Alternatively, vomited blood may have the appearance of coffee grounds if bleeding has slowed or stopped, due to the partial digestion of the blood by acid in the stomach.

Blood may also be passed from the rectum, either as black, tarry stools (melena), as bright red blood (hematochezia), or in apparently normal stool if bleeding is less than a few teaspoons per day. Melena is more likely when bleeding comes from the esophagus, stomach, or small intestine. The black color of melena is caused by blood that has been exposed for several hours to stomach acid and enzymes and to bacteria that normally reside in the large intestine. Melena may continue for several days after bleeding has stopped. Hematochezia is more likely when bleeding comes from the large intestine, although it can be caused by very rapid bleeding from the upper portions of the digestive tract as well.

People who have lost only a small amount of blood may feel well otherwise. However, serious and sudden blood loss may be accompanied by a rapid pulse, low blood pressure, and reduced urine flow. A person may also have cold, clammy hands and feet. Severe bleeding may reduce the flow of blood to the brain, causing confusion, disorientation, sleepiness, and even extremely low blood pressure (shock). Slow, chronic blood loss may cause symptoms and signs of anemia (such as weakness, easy fatigue, paleness [pallor], chest pain, and dizziness). People with underlying ischemic heart disease may develop chest pain (angina) or a have a heart attack (myocardial infarction) because of decreased blood flow through the heart.

Causes

The causes are divided into three areas: upper GI tract, lower GI tract, and small intestine (see Table: Some Causes and Features of Gastrointestinal Bleeding).

The most common causes are difficult to specify because causes vary by the area that is bleeding and the person's age.

However, in general, the most common causes of upper GI bleeding are

  • Ulcers or erosions of the esophagus, stomach, or duodenum

  • Enlarged veins in the esophagus (esophageal varices)

  • A tear in the lining of the esophagus after vomiting (Mallory-Weiss syndrome)

The most common causes of lower GI bleeding are

  • Polyps of the large intestine

  • Diverticular disease

  • Hemorrhoids

  • Inflammatory bowel disease

  • Colon cancer

Other causes of lower GI bleeding include abnormal blood vessels in the colon, a split in the skin of the anus (anal fissure), ischemic colitis, and large bowel inflammation resulting from radiation or poor blood supply.

Bleeding from the small intestine is rare but can result from blood vessel abnormalities, tumors, or a Meckel diverticulum (see Meckel Diverticulum).

Bleeding from any cause is more likely, and potentially more severe, in people who have chronic liver disease (caused by alcohol abuse or chronic hepatitis), who have hereditary disorders of blood clotting, or who are taking certain drugs. Drugs that can cause or worsen bleeding include anticoagulants (such as heparin and warfarin), those that affect platelet function (such as aspirin and certain other nonsteroidal anti-inflammatory drugs [NSAIDs] and clopidogrel), and those that affect the stomach's protective barrier against acid (such as NSAIDs).

Evaluation

GI bleeding typically requires evaluation by a doctor. The following information can help people decide when a doctor’s evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people with GI bleeding, certain symptoms and characteristics are cause for concern. They include

  • Fainting (syncope)

  • Sweating (diaphoresis)

  • Rapid heart rate (over 100 beats per minute)

  • Passing more than 1 cup (250 milliliters) of blood

When to see a doctor

People who have GI bleeding should see a doctor right away unless the only sign of bleeding is black stool or blood on the toilet paper after a bowel movement. If people with such findings have no warning signs and feel otherwise well, a delay of a day or two is not harmful.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the GI bleeding and the tests that may need to be done (see Table: Some Causes and Features of Gastrointestinal Bleeding).

The history is focused on finding out exactly where the bleeding is coming from, how rapid it is, and what is causing it. Doctors need to know how much blood (for instance, a few teaspoons or several clots) is being passed and how often blood is being passed. Doctors ask people with hematemesis whether blood was passed the first time they vomited or only after they vomited a few times with no blood.

Doctors ask people with rectal bleeding whether pure blood was passed; whether it was mixed with stool, pus, or mucus; or whether blood simply coated the stool. People with bloody diarrhea are asked about recent travel or other possible forms of exposure to other agents that can cause digestive tract illness (for instance, food poisoning).

Doctors then ask about symptoms of abdominal discomfort, weight loss, and easy bleeding or bruising and symptoms of anemia (such as weakness, easy exhaustion [fatigability], and dizziness).

Doctors need to know about any current or past digestive tract bleeding and the results of any previous colonoscopy (examination of the entire large intestine, the rectum, and the anus using a flexible viewing tube). People should tell doctors whether they have inflammatory bowel disease, bleeding tendencies, and liver disease and whether they use any drugs that increase the likelihood of bleeding or chronic liver disease (such as alcohol).

The physical examination is focused on the person’s vital signs (such as pulse, breathing rate, blood pressure, and temperature) and other indicators of shock or a decrease in the volume of circulating blood (hypovolemia—rapid heart rate, rapid breathing, pallor, sweating, little urine production, and confusion) and anemia.

Doctors also look for small purplish red (petechiae) and bruise-like (ecchymoses) spots on the skin, which are signs of bleeding disorders. Doctors also look for signs of chronic liver disease (such as spider angiomas, fluid in the abdominal cavity [ascites], and red palms) and portal hypertension (such as an enlarged spleen [splenomegaly] and dilated abdominal wall veins).

Doctors do a rectal examination to search for stool color, masses, and fissures and to check the stool for blood. Doctors also examine the anus to look for hemorrhoids.

Some Causes and Features of Gastrointestinal Bleeding

Cause*

Common Features

Tests

Upper digestive tract (indicated by vomiting blood or dark brown material)

Ulcers or erosions of the esophagus, stomach, or first part of the small intestine (duodenum)

Pain that

  • Is steady and mild or moderately severe

  • Is usually located just below the breastbone

  • May awaken the person during the night and/or be relieved by eating

Upper GI endoscopy (examination of esophagus, stomach, and duodenum using a flexible viewing tube called an endoscope)

Sometimes angiography (x-rays taken after injecting a dye that can be seen on x-rays into an artery through a catheter)

Esophageal varices (enlarged veins in the esophagus)

Usually very heavy bleeding

Often in people known to have chronic liver disease such as cirrhosis

Sometimes signs of chronic liver disease such as a swollen abdomen and yellowish discoloration of the skin and whites of the eyes (jaundice)

Upper GI endoscopy

Mallory-Weiss tear (a tear in the esophagus caused by vomiting—see Esophageal Laceration (Mallory-Weiss Syndrome))

In people who vomited one or more times before they started vomiting blood

Sometimes pain in the lower chest during vomiting

Upper GI endoscopy

Abnormal growths in blood vessels (such as angiomas)

Sometimes pink, red, purple, or reddish brown patches on the skin around or inside the mouth

Upper GI endoscopy

Abnormal connections between the arteries and veins (arteriovenous malformations) in the intestine

Usually no other symptoms

Upper GI endoscopy

Lower digestive tract (indicated by passing blood in the stool)

Anal fissures

Pain during bowel movements

Bright red blood only on toilet paper or on the surface of formed stools

Fissure seen during the doctor's examination

A doctor’s examination

Abnormal blood vessels (angiodysplasia) in the intestine

Painless, bright red blood from the rectum (hematochezia)

Colonoscopy (examination of the entire large intestine, rectum, and anus using an endoscope)

Inflammation of the large intestine due to radiation therapy, infection, or disruption of the blood supply (as occurs in ischemic colitis)

Bloody diarrhea, fever, and abdominal pain

Colonoscopy

Colon cancer

Sometimes fatigue, weakness, and/or a bloating sensation

Usually in middle-aged or older people

Colonoscopy and biopsy (examination of tissue samples taken from the lining of the intestine)

Colon polyps

Often no other symptoms

Colonoscopy

Diverticular disease (such as diverticulosis)

Painless hematochezia

Sometimes in people already known to have diverticular disease

Colonoscopy

Inflammatory bowel disease (such as ulcerative proctitis, ulcerative colitis, or Crohn disease)

Bloody diarrhea, fever, and abdominal pain and cramps

Sometimes in people who have had several episodes of bleeding from the rectum

Colonoscopy and biopsy

Internal hemorrhoids

Bright red blood only on toilet paper or on the surface of formed stools

Anoscopy (examination of the anus and rectum with a short, rigid tube) or sigmoidoscopy

*Causes are listed in order from the most common to the least.

Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

GI = gastrointestinal.

Testing

The need for tests depends on what doctors find during the history and physical examination, particularly whether warning signs are present.

There are four main testing approaches to GI bleeding:

  • Blood tests and other laboratory studies

  • Upper endoscopy for suspected upper GI tract bleeding

  • Colonoscopy for lower GI tract bleeding (unless clearly caused by hemorrhoids)

  • Angiography if bleeding is rapid or severe

The person’s blood count helps indicate how much blood has been lost. A low platelet count is a risk factor for bleeding. Other blood tests include prothrombin time (PT), partial thromboplastin time (PTT), and tests of liver function, all of which help detect problems with blood clotting. Doctors often do not do blood tests on people who have minor bleeding caused by hemorrhoids.

If the person has vomited blood or dark material (which may represent partially digested blood), the doctor sometimes passes a small, hollow plastic tube through the person’s nose down into the stomach (nasogastric tube—see Intubation of the Digestive Tract) and suctions out the stomach contents. Bloody or pink contents indicate active upper GI bleeding, and dark or coffee-ground material indicates that bleeding is slow or has stopped. Sometimes, there is no sign of blood even though the person was bleeding very recently. A nasogastric tube may be inserted in anyone who has not vomited but has passed a large amount of blood from the rectum (if not from an obvious hemorrhoid) because this blood may have originated in the upper digestive tract.

If the nasogastric tube reveals signs of active bleeding, or the person’s symptoms strongly suggest the bleeding is originating in the upper digestive tract, the doctor usually does upper endoscopy. Upper endoscopy is a visual examination of the esophagus, stomach, and the first segment of the small intestine (duodenum) using a flexible tube called an endoscope. An upper endoscopy allows the doctor to see the bleeding source and often treat it and is often done without a nasogastric tube being passed.

People with symptoms typical of hemorrhoids may need only sigmoidoscopy (examination of the lower part of the large intestine, the rectum, and anus using an endoscope). All other people with hematochezia should have colonoscopy (examination of the entire large intestine, the rectum, and the anus using an endoscope).

Rarely, endoscopy (both upper and lower) and colonoscopy do not show the cause of bleeding. There are still other options for finding the source of the bleeding. Doctors may do a small-bowel follow-through, which is a series of detailed x-rays of the small intestine. Doctors may do endoscopy of the small bowel (enteroscopy). If bleeding is rapid or severe, doctors sometimes do angiography. During angiography, doctors use a catheter to inject an artery with a dye that can be seen on x-rays. Angiography helps doctors diagnose upper digestive tract bleeding and allows them to do certain treatments (such as embolization and vasoconstrictor infusion—see Stopping the bleeding). Doctors may also inject the person with red blood cells labeled with a radioactive marker (radionuclide scanning—see Radionuclide Scanning). With the use of a special scanning camera, the radioactive marker can sometimes show the approximate location of the bleeding.

Another option is video capsule endoscopy (see Video Capsule Endoscopy), in which people swallow a tiny camera that takes pictures as it passes through the intestines. Video capsule endoscopy is especially useful in the small intestine but it is not very useful in either the colon or stomach, because these organs are too big to get good pictures of their inner lining.

Treatment

There are two goals to treating people with GI bleeding:

  • Replace lost blood with fluid given by vein (intravenously) and sometimes with a blood transfusion

  • Stop any ongoing bleeding

Hematemesis, hematochezia, or melena should be considered an emergency. People with severe GI bleeding should be admitted to an intensive care unit and should be seen by a gastroenterologist and a surgeon.

Fluid replacement

People with sudden, severe blood loss require intravenous fluids and sometimes an emergency blood transfusion to stabilize their condition. People with blood clotting abnormalities may require transfusion of platelets, fresh frozen plasma, or blood clotting factors or injections of vitamin K.

Stopping the bleeding

Most GI bleeding stops without treatment. Sometimes, however, it does not. The type and location of bleeding tells the doctors what treatment to use. For example, doctors can often stop peptic ulcer bleeding during endoscopy by using a device that uses an electrical current to produce heat (electrocautery), heater probes, laser, or injections of certain drugs (injection sclerotherapy). If endoscopy does not stop the bleeding, surgery is required.

Doctors stop bleeding of varicose veins with endoscopic banding, injection sclerotherapy, or a transjugular intrahepatic portosystemic shunting (TIPS—see Portal Hypertension : Treatment) procedure.

Doctors can sometimes control severe, ongoing lower GI bleeding caused by diverticula or angiomas during colonoscopy by using an electrocautery device, coagulation with a heater probe, or injection with epinephrine. Polyps can be removed by a wire snare or electrocautery. If these methods do not work or are impossible, doctors do angiography (see Symptoms of Digestive Disorders:Testing) during which they may pass a catheter into the bleeding vessel and then inject a chemical, fragments of a gelatin sponge, or a wire coil to block the blood vessel and thereby stop the bleeding (embolization) or inject vasopressin to reduce blood flow to the bleeding vessel. People with continued bleeding may need surgery, so it is important for doctors to know the location of the bleeding site.

Internal hemorrhoid bleeding stops spontaneously in most cases. For people whose bleeding does not stop without treatment, doctors do anoscopy and may place rubber bands around the hemorrhoids or inject them with substances that stop bleeding or do electrocautery or surgery.

Essentials for Older People

In older people, hemorrhoids and colorectal cancer are the most common causes of minor bleeding. Peptic ulcers, diverticular disease (such as diverticulitis), and abnormal blood vessels (angiodysplasia) are the most common causes of major bleeding. Bleeding from enlarged veins in the esophagus (esophageal varices) is less common than in younger people.

Older people poorly tolerate massive GI bleeding. Doctors must diagnosis older people quickly, and treatment must be started sooner than in younger people, who can better tolerate repeated episodes of bleeding.

Key Points

  • Rectal bleeding may result from upper or lower GI bleeding.

  • Most people stop bleeding spontaneously.

  • Endoscopy is usually the first choice for people whose bleeding will not stop without treatment.

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • PANHEPRIN
  • No US brand name
  • COUMADIN
  • PLAVIX
  • ADRENALIN
  • VASOSTRICT