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Gastrointestinal bleeding

1. Hematemesis

Definition

Hematemesis is vomiting of gross blood. It is diagnostic of bleeding from any site proximal to the ligament of Treitz.

Assessment

1. resuscitation
2. nasopharyngeal tube
3. lab assessment
4. endoscopy within 48hrs
5. medical therapy / surgery

Sources of hematemesis

• Esophagus
  •   Esophagitis
  •   Ulcer
  •   Mallory-Weiss tear
  •   Esophageal varices
• Stomach
  •   Gastric ulcer
  •   Prepyloric ulcer
  •   Pyloric channel ulcer
  •   Gastric erosions
  •   Gastritis
  •   Varices
  •   Portal-hypertensive gastropathy
  •   Gastric cancer
  •   Polyp
  •   Dieulafoy lesion
• Duodenum
  •   Ulcer
  •   Duodenitis
  •   Aortoenteric fistula
  •   Pancreatic pseudocyst
  •   Post-sphincterotomy

Melenemesis, or "coffee grounds" vomiting, occurs when blood is in contact with gastric acid for at least 1 hour.

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2. Melena

Definition

The passage of dark black, liquid, tarry, metallic-smelling stools. Melenic stools usually indicate bleeding proximal to the right side of the colon. It usually indicates that hemorrhage has remained for > 8hrs in the GI tract.

Assessment

Assessment depends on whether the patient is actively bleeding or if the bleeding has stopped.

1. Actively bleeding patients:
   1. UGI endoscopy
   2. arteriography
   3. scan
2. If not bleeding:
   1. endoscopy
   2. elective colonoscopy

Sources of melena

• All causes of upper gastrointestinal bleeding
• Jejunum and ileum: (Meckel's diverticulum, angiodysplasia, Chron's disease, tumors, bowel infarction).
• Colon: right sided tumors, angiodysplasia, inflammatory bowel disease.

3. Blood intermixed with stools

Results when the source of bleeding arises from the colon.

Assessment includes colonoscopy

Sources of bleeding

• left sided colonic tumors
• inflammatory bowel disease
• diverticular disease
• infective colitis
• angiodysplasia
• ischemic colitis

4. Hematocezia

Definition

The passage of bright red stools. Is usually indicative of bleeding from the rectum & anus, however 50% are due to proximal lesions (mainly in the colon) that are profuse enough that they avoid remaining in the gut for 8hrs & are not expressed as blood intermixed with stools.

Assessment

Assessment includes PR examination if nothing is found then order an anoscopy, proctosigmoidoscopy and lastly colonoscopy.

Sources of hematocezia

• Colonic cancer
• Colonic polyps
• Diverticula
• Colitis
• Vascular ectasia
• Large hemorrhoids only
• Ulcer tear (rectum)
• Upper gastrointestinal or small bowel source
• No site identified

5. Occult blood in stools

The use of this lab test is limited to premenopausal woman with anemia and no history of menorrhagia. Or as a screening test for large bowel malignancy. It should not be used as the investigation that determines the cause of <a href="../../diagnosis/anemia/index.htm">anemia</a> in men / postmenopausal women as in these cases the cause is almost always due to GI cause even if FOBT is negative. In such cases FOBT is a useful indicator to whether the cause could be in the lower GIT (FOBT positive) or in the upper GIT (FOBT negative).

Assessment includes:

• history and exam to suggest the most likely site of bleeding.
• colonoscopy is done before UGI endoscopy in the same session..(barium enema if colonoscopy not available) --> small bowel follow through although the diagnostic yield is low. enteroscopy may be needed. Arteriography.
• ANY POSSIBLE LESIONS ARE BIOPSIED.

Source of bleeding

1. Occult Bleeding with Signs of Upper Gastrointestinal Hemorrhage

• Epistaxis
• Hemoptysis
• Gingival/glossal/pharyngeal bleeding
• Ingestion of blood--human or animal
• Gastric cardia varices
• Antral/duodenal varices
• Dieulafoy lesions
• Pancreaticobiliary bleeding
  •   Pancreatic pseudoaneurysm
  •   Hepatic neoplasms/trauma
• Aortoduodenal fistula
• Duodenal diverticulum
• Vascular ectasias

2. Occult Bleeding with Signs of Lower Gastrointestinal Hemorrhage

• Briskly bleeding duodenal ulcers
• Small bowel Dieulafoy lesions
• Vascular ectasias of colon
• Meckel's diverticulum--distal ileum
• Aortocolonic or arteriocolonic fistula
• Solitary colonic ulcers
• Colorectal varices

3. Blood Loss without Signs/Symptoms of Either Upper or Lower Bleeding

• Small bowel neoplasms
  •   Adenocarcinoma
  •   Sarcoma, leiomyoma
  •   Lymphoma
  •   Metastases--breast, lung, melanoma
• Vascular ectasias
• Crohn's disease of small bowel
• Dieulafoy lesions
• Small bowel varices

6. Chronic GIT bleeding causing anemia

Assessment includes:

1. history and exam to suggest the most likely site of bleeding.
2. colonoscopy is done before UGI endoscopy in the same session (barium enema if colonoscopy not available) if the FOBT is positive, otherwise if negative then endoscopy should precede colonoscopy.
3. small bowel follow through although the diagnostic yield is low.
4. enteroscopy may be needed.
5. Arteriography.
6. ANY POSSIBLE LESIONS ARE BIOPSIED.

Sources of bleeding

• Colon
  •   Cancer
  •   Polyp
  •   Vascular ectasia
  •   Colitis
  •   Cecal ulcer
  •   Parasites
• Upper gastrointestinal tract
  •   Duodenal ulcer
  •   Esophagitis
  •   Gastritis
  •   Gastric ulcer
  •   Vascular ectasia
  •   Anastomotic ulcer
  •   Gastric cancer
  •   Portal hypertensive gastropathy
  •   Adenomatous polyp

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