Gastrointestinal bleeding
Encyclopedia
Gastrointestinal bleeding or gastrointestinal hemorrhage describes every form of hemorrhage (loss of blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....

) in the gastrointestinal tract
Gastrointestinal tract
The human gastrointestinal tract refers to the stomach and intestine, and sometimes to all the structures from the mouth to the anus. ....

, from the pharynx
Pharynx
The human pharynx is the part of the throat situated immediately posterior to the mouth and nasal cavity, and anterior to the esophagus and larynx. The human pharynx is conventionally divided into three sections: the nasopharynx , the oropharynx , and the laryngopharynx...

 to the rectum
Rectum
The rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long...

. It has diverse causes, and a medical history, as well as physical examination
Physical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...

, generally distinguishes between the main forms. The degree of bleeding can range from nearly undetectable to acute, massive, life-threatening bleeding.

Initial emphasis is on resuscitation by infusion of intravenous fluids
Intravenous therapy
Intravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...

 and blood transfusion
Blood transfusion
Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood...

, treatment with proton pump inhibitor
Proton pump inhibitor
Proton-pump inhibitors are a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available today. The group followed and has largely superseded another group of pharmaceuticals with similar...

s and occasionally with vasopressin
Vasopressin
Arginine vasopressin , also known as vasopressin, argipressin or antidiuretic hormone , is a neurohypophysial hormone found in most mammals, including humans. Vasopressin is a peptide hormone that controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue's...

 analogues and tranexamic acid
Tranexamic acid
Tranexamic acid is a drug used to treat or prevent excessive blood loss during surgery and in certain other conditions...

. Upper endoscopy or colonoscopy
Colonoscopy
Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It may provide a visual diagnosis and grants the opportunity for biopsy or removal of suspected...

 are generally considered appropriate to identify the source of bleeding and carry out therapeutic interventions.

Definition

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
Iron deficiency anemia
Iron-deficiency anemia is a common anemia that occurs when iron loss occurs, and/or the dietary intake or absorption of iron is insufficient...

), to massive bleeding where pure blood is passed and hypovolemia
Hypovolemia
In physiology and medicine, hypovolemia is a state of decreased blood volume; more specifically, decrease in volume of blood plasma...

 and shock may develop, risking death
Death
Death is the permanent termination of the biological functions that sustain a living organism. Phenomena which commonly bring about death include old age, predation, malnutrition, disease, and accidents or trauma resulting in terminal injury....

.

Differential diagnosis

Gastrointestinal bleeding can be roughly divided into two clinical syndromes.

Upper gastrointestinal

Upper gastrointestinal bleeding is from a source between the pharynx
Pharynx
The human pharynx is the part of the throat situated immediately posterior to the mouth and nasal cavity, and anterior to the esophagus and larynx. The human pharynx is conventionally divided into three sections: the nasopharynx , the oropharynx , and the laryngopharynx...

 and the ligament of Treitz
Suspensory muscle of the duodenum
The Suspensory muscle of duodenum or Ligament of Treitz connects the duodenum of the small intestines to the diaphragm. It contains a slender band of skeletal muscle from the diaphragm and a fibromuscular band of smooth muscle from the horizontal and ascending parts of the duodenum...

. An upper source is characterised by hematemesis
Hematemesis
Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract. Patients can easily confuse it with hemoptysis , although the latter is more common.-Signs:...

 (vomiting up blood) and melena
Melena
In medicine, melena or melaena refers to the black, "tarry" feces that are associated with gastrointestinal hemorrhage. The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon.-Melena vs...

 (tarry stool containing altered blood).

Lower gastrointestinal

Lower gastrointestinal bleeding may be indicated by red blood per rectum, especially in the absence of hematemesis
Hematemesis
Hematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract. Patients can easily confuse it with hemoptysis , although the latter is more common.-Signs:...

. Isolated melena may originate from anywhere between the stomach and the proximal colon.

Diagnostic approach

Diagnosis is often based on direct observation of blood in the stool. This can be confirmed with a fecal occult blood
Fecal occult blood
Fecal occult blood refers to blood in the feces that is not visibly apparent. A fecal occult blood test checks for hidden blood in the stool...

 test.

Treatment

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.
  • Fluid resuscitation: intravenous fluids and blood transfusion
    Blood transfusion
    Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood...

     may be administered.
  • Acid suppression: in an upper GI source, proton pump inhibitor
    Proton pump inhibitor
    Proton-pump inhibitors are a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available today. The group followed and has largely superseded another group of pharmaceuticals with similar...

    s reduce gastric acid
    Gastric acid
    Gastric acid is a digestive fluid, formed in the stomach. It has a pH of 1 to 2 and is composed of hydrochloric acid , and large quantities of potassium chloride and sodium chloride...

     production and enhance healing of bleeding lesions.
  • Inhibition of fibrinolysis: in ongoing bleeding, tranexamic acid
    Tranexamic acid
    Tranexamic acid is a drug used to treat or prevent excessive blood loss during surgery and in certain other conditions...

     reduces fibrinolysis
    Fibrinolysis
    Fibrinolysis is a process that prevents blood clots from growing and becoming problematic. This process has two types: primary fibrinolysis and secondary fibrinolysis...

     and may decrease blood product requirements.
  • Correction of coagulopathy: if coagulation
    Coagulation
    Coagulation is a complex process by which blood forms clots. It is an important part of hemostasis, the cessation of blood loss from a damaged vessel, wherein a damaged blood vessel wall is covered by a platelet and fibrin-containing clot to stop bleeding and begin repair of the damaged vessel...

     parameters (e.g. prothrombin time
    Prothrombin time
    The prothrombin time and its derived measures of prothrombin ratio and international normalized ratio are measures of the extrinsic pathway of coagulation. This test is also called "ProTime INR" and "INR PT". They are used to determine the clotting tendency of blood, in the measure of warfarin...

    ) are deranged, vitamin K
    Vitamin K
    Vitamin K is a group of structurally similar, fat soluble vitamins that are needed for the posttranslational modification of certain proteins required for blood coagulation and in metabolic pathways in bone and other tissue. They are 2-methyl-1,4-naphthoquinone derivatives...

     or fresh frozen plasma
    Fresh frozen plasma
    The term fresh frozen plasma refers to the liquid portion of human blood that has been frozen and preserved after a blood donation and will be used for blood transfusion...

     may need to be administered.
  • Reduction of portal pressure: if the bleeding is thought to be due to esophageal varices
    Esophageal varices
    In medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...

     (a complication of cirrhosis
    Cirrhosis
    Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...

     of the liver), vasopressin
    Vasopressin
    Arginine vasopressin , also known as vasopressin, argipressin or antidiuretic hormone , is a neurohypophysial hormone found in most mammals, including humans. Vasopressin is a peptide hormone that controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue's...

     analogues and rarely octreotide
    Octreotide
    Octreotide is an octapeptide that mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of growth hormone, glucagon, and insulin than the natural hormone...

     may be administered. Rarely, a Sengstaken-Blakemore tube
    Sengstaken-Blakemore tube
    A Sengstaken-Blakemore tube is a medical device inserted through the nose or mouth and used occasionally in the management of upper gastrointestinal hemorrhage due to esophageal varices...

     or Minnesota tube may be inserted to mechanically compress varices.
  • Urgent endoscopy: if the bleeding cannot be managed medically an urgent esophagogastroduodenoscopy
    Esophagogastroduodenoscopy
    For other expansions of the initialism "OGD", see the disambiguation page.In medicine , esophagogastroduodenoscopy is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum...

     (EGD/OGD) may identify sources of bleeding. This is a high-risk procedure best performed under safe circumstances in the intensive care unit
    Intensive Care Unit
    thumb|220px|ICU roomAn intensive-care unit , critical-care unit , intensive-therapy unit/intensive-treatment unit is a specialized department in a hospital that provides intensive-care medicine...

     or operating theatre
    Operating theatre
    An operating theater was a non-sterile, tiered theater or amphitheater in which students and other spectators could watch surgeons perform surgery...

    s.
  • Surgical intervention: in extreme cases of bleeding, laparotomy
    Laparotomy
    A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...

     may be required to identify the bleeding source.

Endoscopy

After adequate stabilization, endoscopy
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...

 (upper endoscopy and/or colonoscopy
Colonoscopy
Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It may provide a visual diagnosis and grants the opportunity for biopsy or removal of suspected...

) are used to identify the source of bleeding. Injection, sclerotherapy, electrocoagulation, vascular clipping
Endoclip
An endoclip is a metallic mechanical device used in endoscopy in order to close two mucosal surfaces without the need for surgery and suturing. Its function is similar to a suture in gross surgical applications, as it is used to join together two disjointed surfaces, but, can be applied through...

 and biopsy may be performed.

Endoscopy is also useful in setting the indication for therapy, e.g. the need for long-term proton pump inhibitor
Proton pump inhibitor
Proton-pump inhibitors are a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available today. The group followed and has largely superseded another group of pharmaceuticals with similar...

 therapy, presence of esophageal varices
Esophageal varices
In medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...

, adenomatous polyps and so on.
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