Gastrointestinal Bleeding

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

People who have GI bleeding should see a doctor right away unless the only sign of bleeding is 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.

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 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. People with hematemesis are asked 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, bacterial infections).

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 (an 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 Overview of Inflammatory Bowel Disease (IBD) In inflammatory bowel diseases, the intestine (bowel) becomes inflamed, often causing recurring abdominal pain and diarrhea. The two primary types of inflammatory bowel disease (IBD) are Crohn... read more , bleeding tendencies, or liver disease and whether they use any medications that increase the likelihood of bleeding (such as aspirin, NSAIDs, or anticoagulants) or drugs that can cause 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 Ascites Ascites is the accumulation of protein-containing (ascitic) fluid within the abdomen. Many disorders can cause ascites, but the most common is high blood pressure in the veins that bring blood... read more ], and red palms) and portal hypertension Portal Hypertension Portal hypertension is abnormally high blood pressure in the portal vein (the large vein that brings blood from the intestine to the liver) and its branches. Cirrhosis (scarring that distorts... read more (such as an enlarged spleen and dilated abdominal wall veins).

Doctors do a rectal examination to look at stool color and check it for blood and to search for tumors and fissures Anal Fissure An anal fissure is a tear or ulcer in the lining of the anus (the opening at the end of the digestive tract where stool leaves the body). Anal fissures may occur after passage of hard or large... read more . Doctors also examine the anus to look for hemorrhoids Hemorrhoids Hemorrhoids are dilated, twisted blood vessels located in the wall of the lower rectum and anus. The swollen vessels are caused by an increase in pressure. Lumps form inside or outside of the... read more .

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:

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 liver tests, 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 Intubation of the Digestive Tract Intubation of the digestive tract is the process of passing a small, flexible plastic tube through the nose or mouth into the stomach (nasogastric intubation) or small intestine (nasoenteric... read more ) 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 Endoscopy Endoscopy is an examination of internal structures using a flexible viewing tube (endoscope). In addition to examinations, doctors can use endoscopy to do biopsies and give treatment. Endoscopes... read more 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) or anoscopy (examination of only the rectum, using a short scope and light source). All other people with hematochezia should have colonoscopy (examination of the entire large intestine, the rectum, and the anus using an endoscope).

Occasionally, upper endoscopy and colonoscopy do not show the cause of bleeding. There are still other options for finding the source of the bleeding. Doctors may do endoscopy of the small bowel (enteroscopy). If bleeding is rapid or severe, doctors sometimes do angiography Angiography In angiography, x-rays are used to produce detailed images of blood vessels. It is sometimes called conventional angiography to distinguish it from computed tomography (CT) angiography and magnetic... read more . During angiography, doctors use a catheter to inject an artery with a contrast agent 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 Stopping the bleeding Bleeding may occur anywhere along the digestive (gastrointestinal or GI) tract, from the mouth to the anus. Blood may be easily seen by the naked eye (overt), or blood may be present in amounts... read more ). Doctors may also inject the person with red blood cells labeled with a radioactive marker (radionuclide scanning Radionuclide Scanning In radionuclide scanning, radionuclides are used to produce images. A radionuclide is a radioactive form of an element, which means it is an unstable atom that becomes more stable by releasing... read more ). With the use of a special scanning camera, the radioactive marker can sometimes show the approximate location of the bleeding. Before doing angiography or surgery, doctors may also do a test called CT angiography CT angiography In computed tomography (CT), which used to be called computed axial tomography (CAT), an x-ray source and x-ray detector rotate around a person. In modern scanners, the x-ray detector usually... read more . During this procedure, a type of imaging called computed tomography (CT) and a radiopaque contrast agent are used to produce images of blood vessels and sometimes can show the location of the bleeding.

Doctors may do a small-bowel follow-through, which is a series of detailed x-rays of the small intestine. This test has largely been replaced by CT enterography CT Enterography and MR Enterography Computed tomography (CT) and magnetic resonance imaging (MRI) scans are good tests for assessing the size and location of abdominal organs. Additionally, cancerous (malignant) or noncancerous... read more , which is used to evaluate the inside of the small intestine for tumors.

Another option is video capsule endoscopy Video Capsule Endoscopy Video capsule endoscopy (wireless video endoscopy) is a procedure in which the person swallows a battery-powered capsule. The capsule contains one or two small cameras, a light, and a transmitter... read more , 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 easier to see using endoscopy.

People with sudden, severe blood loss require intravenous fluids and sometimes an emergency blood transfusion Overview of Blood Transfusion A blood transfusion is the transfer of blood or a blood component from one healthy person (a donor) to a sick person (a recipient). Transfusions are given to increase the blood's ability to... read more to stabilize their condition. People with blood clotting abnormalities may require transfusion of platelets Platelets People are sometimes given transfusions of whole blood during severe bleeding (for example after an injury or pregnancy complications), but usually they are given only the blood component they... read more or fresh frozen plasma Plasma People are sometimes given transfusions of whole blood during severe bleeding (for example after an injury or pregnancy complications), but usually they are given only the blood component they... read more or preparations of blood clotting proteins (prothrombin complex concentrates).

Most GI bleeding stops without treatment. Sometimes, however, it does not. The type and location of bleeding tell 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, or injections of certain agents. If endoscopy does not stop the bleeding, surgery may be needed.

For esophageal varices Esophageal Varices Esophageal varices are enlarged veins in the esophagus, which can cause major bleeding. Esophageal varices are caused by high blood pressure in blood vessels in and around the liver (portal... read more (enlarged veins in the esophagus), doctors try to stop bleeding with endoscopic banding, injection sclerotherapy, placement of a tube with balloons to compress the varices, or a transjugular intrahepatic portosystemic shunting Treatment Portal hypertension is abnormally high blood pressure in the portal vein (the large vein that brings blood from the intestine to the liver) and its branches. Cirrhosis (scarring that distorts... read more procedure. People with esophageal varices may be given injections of the medication octreotide to help stop the bleeding. Antibiotics may also be given.

Doctors can sometimes control severe, ongoing lower GI bleeding caused by diverticula or angiodysplasias during colonoscopy by using clips, an electrocautery device, coagulation with a heater probe, or injection with epinephrine. If these methods do not work or are impossible, doctors do angiography 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 give intravenous 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.

Polyps can be removed by a wire snare or electrocautery.

Doctors may give people with upper GI bleeding a proton pump inhibitor (PPI) by vein (intravenously) to help control the bleeding.

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 (see treatment of hemorrhoids Treatment Hemorrhoids are dilated, twisted blood vessels located in the wall of the lower rectum and anus. The swollen vessels are caused by an increase in pressure. Lumps form inside or outside of the... read more ).