Gastrointestinal bleeding

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Gastrointestinal bleeding
Other namesGastrointestinal hemorrhage, GI bleed
Positive fecal occult blood test.jpg
A positive fecal occult blood test
Specialty Gastroenterology   OOjs UI icon edit-ltr-progressive.svg
Symptoms Vomiting red blood, vomiting black blood, bloody stool, black stool, feeling tired [1]
Complications Iron-deficiency anemia, heart-related chest pain [1]
Types Upper gastrointestinal bleeding, lower gastrointestinal bleeding [2]
CausesUpper: peptic ulcer disease, esophageal varices due to liver cirrhosis, cancer [3]
Lower: hemorrhoids, cancer, inflammatory bowel disease [2]
Diagnostic method Medical history and physical examination, blood tests [1]
Treatment Intravenous fluids, blood transfusions, endoscopy [4] [5]
Medication Proton pump inhibitors, octreotide, antibiotics [5] [6]
Prognosis ~15% risk of death [1] [7]
FrequencyUpper: 100 per 100,000 adults per year [8]
Lower: 25 per 100,000 per year [2]

Gastrointestinal bleeding (GI bleed), also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. [9] When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. [1] Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. [1] Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. [1] [9] Sometimes in those with small amounts of bleeding no symptoms may be present. [1]

Contents

Bleeding is typically divided into two main types: upper gastrointestinal bleeding and lower gastrointestinal bleeding. [2] Causes of upper GI bleeds include: peptic ulcer disease, esophageal varices due to liver cirrhosis and cancer, among others. [3] Causes of lower GI bleeds include: hemorrhoids, cancer, and inflammatory bowel disease among others. [2] [1] Small amounts of bleeding may be detected by fecal occult blood test. [1] Endoscopy of the lower and upper gastrointestinal tract may locate the area of bleeding. [1] Medical imaging may be useful in cases that are not clear. [1]

Initial treatment focuses on resuscitation which may include intravenous fluids and blood transfusions. [4] Often blood transfusions are not recommended unless the hemoglobin is less than 70 or 80 g/L. [7] [10] Treatment with proton pump inhibitors, octreotide, and antibiotics may be considered in certain cases. [5] [6] [11] If other measures are not effective, an esophageal balloon may be attempted in those with presumed esophageal varices. [2] Endoscopy of the esophagus, stomach, and duodenum or endoscopy of the large bowel are generally recommended within 24 hours and may allow treatment as well as diagnosis. [4]

An upper GI bleed is more common than lower GI bleed. [2] An upper GI bleed occurs in 50 to 150 per 100,000 adults per year. [8] A lower GI bleed is estimated to occur in 20 to 30 per 100,000 per year. [2] It results in about 300,000 hospital admissions a year in the United States. [1] Risk of death from a GI bleed is between 5% and 30%. [1] [7] Risk of bleeding is more common in males and increases with age. [2]

Classification

Causes of gastrointestinal bleeding Causes of gastrointestinal bleeding.png
Causes of gastrointestinal bleeding

Gastrointestinal bleeding can be roughly divided into two clinical syndromes: upper gastrointestinal bleeding and lower gastrointestinal bleeding. [2] About 2/3 of all GI bleeds are from upper sources and 1/3 from lower sources. [12] Common causes of gastrointestinal bleeding include infections, cancers, vascular disorders, adverse effects of medications, and blood clotting disorders. [2] Obscure gastrointestinal bleeding (OGIB) is when a source is unclear following investigation. [13]

Upper gastrointestinal

Upper gastrointestinal bleeding is from a source between the pharynx and the ligament of Treitz. An upper source is characterised by hematemesis (vomiting up blood) and melena (tarry stool containing altered blood). About half of cases are due to peptic ulcer disease (gastric or duodenal ulcers). [3] Esophageal inflammation and erosive disease are the next most common causes. [3] In those with liver cirrhosis, 50–60% of bleeding is due to esophageal varices. [3] Approximately half of those with peptic ulcers have an H. pylori infection. [3] Other causes include Mallory-Weiss tears, cancer, and angiodysplasia. [2]

A number of medications are found to cause upper GI bleeds. [14] NSAIDs or COX-2 inhibitors increase the risk about fourfold. [14] SSRIs, corticosteroids, and anticoagulants may also increase the risk. [14] The risk with dabigatran is 30% greater than that with warfarin. [15]

Lower gastrointestinal

Lower gastrointestinal bleeding is typically from the colon, rectum or anus. [2] Common causes of lower gastrointestinal bleeding include hemorrhoids, cancer, angiodysplasia, ulcerative colitis, Crohn's disease, and aortoenteric fistula. [2] It may be indicated by the passage of fresh red blood rectally, especially in the absence of bloody vomiting. Lower gastrointestinal bleeding could also lead to melena if the bleeding occurs in the small intestine or proximal colon. [1]

Signs and symptoms

Gastrointestinal bleeding can range from small non-visible amounts, which are only detected by laboratory testing, to massive bleeding where bright red blood is passed and shock develops. Rapid bleeding may cause syncope. [16] The presence of bright red blood in stool, known as hematochezia, typically indicates lower gastrointestinal bleeding. Digested blood from the upper gastrointestinal tract may appear black rather than red, resulting in "coffee ground" vomit or melena. [2] Other signs and symptoms include feeling tired, dizziness, and pale skin color. [16]

A number of foods and medications can turn the stool either red or black in the absence of bleeding. [2] Bismuth found in many antacids may turn stools black as may activated charcoal. [2] Blood from the vagina or urinary tract may also be confused with blood in the stool. [2]

Diagnosis

Diagnosis is often based on direct observation of blood in the stool or vomit. Although fecal occult blood testing has been used in an emergency setting, this use is not recommended as the test has only been validated for colon cancer screening. [17] Differentiating between upper and lower bleeding in some cases can be difficult. The severity of an upper GI bleed can be judged based on the Blatchford score [4] or Rockall score. [14] The Rockall score is the more accurate of the two. [14] As of 2008 there is no scoring system useful for lower GI bleeds. [14]

Clinical

Gastric aspiration and or lavage, where a tube is inserted into the stomach via the nose in an attempt to determine if there is blood in the stomach, if negative does not rule out an upper GI bleed [18] but if positive is useful for ruling one in. [12] Clots in the stool indicate a lower GI source while melana stools an upper one. [12]

Laboratory testing

Recommended laboratory blood testing includes: cross-matching blood, hemoglobin, hematocrit, platelets, coagulation time, and electrolytes. [4] If the ratio of blood urea nitrogen to creatinine is greater than 30 the source is more likely from the upper GI tract. [12]

Imaging

A CT angiography is useful for determining the exact location of the bleeding within the gastrointestinal tract. [19] Nuclear scintigraphy is a sensitive test for detecting occult gastrointestinal bleeding when direct imaging with upper and lower endoscopies are negative. Direct angiography allows for embolization of a bleeding source, but requires a bleeding rate faster than 1mL/minute. [20]

Prevention

In patients with significant varices or cirrhosis nonselective β-blockers reduce the risk of future bleeding. [11] With a target heart rate of 55 beats per minute B-blockers reduce the absolute risk of bleeding by 10%. [11] Endoscopic band ligation (EBL) is also effective at improving outcomes. [11] Either B-blockers or EBL is recommended as initial preventative measures. [11] In patients who have had a previous variceal bleed both treatments are recommended. [11] Some evidence supports the addition of isosorbide mononitrate. [21] Testing for and treating those who are positive for H. pylori is recommended. [14] Transjugular intrahepatic portosystemic shunting (TIPS) may be used to prevent bleeding in people who re-bleed despite other measures. [14]

Among patients admitted to the ICU with high risk of bleeding, a PPI or H2RA appears useful. [22] [23]

Treatment

The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood. [4] A number of medications may improve outcomes depending on the source of the bleeding. [4]

Peptic ulcers

Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding. [4] Proton pump inhibitor (PPI) treatment before endoscopy may decrease the need for endoscopic hemostatic treatment, however it is not clear if this treatment reduces mortality, the risk of re-bleeding, or the [ clarification needed ] and the need for surgery. [24] Oral and intravenous formulations may be equivalent; however, the evidence to support this is suboptimal. [25] In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance. [24] There is tentative evidence of benefit for tranexamic acid which inhibits clot breakdown. [26] Somatostatin and octreotide, while recommended for varicial bleeding, have not been found to be of general use for non variceal bleeds. [4] After treatment of a high risk bleeding ulcer endoscopically giving a PPI once or a day rather than as an infusion appears to work just as well and is less expensive (the method may be either by mouth or intravenously). [27]

Variceal bleeding

For initial fluid replacement, colloids or albumin is preferred in people with cirrhosis. [4] Medications typically include octreotide or, if not available, vasopressin and nitroglycerin to reduce portal venous pressures. [11] Terlipressin appears to be more effective than octreotide, but it is not available in many areas of the world. [14] [28] It is the only medication that has been shown to reduce mortality in acute variceal bleeding. [28] This is in addition to endoscopic banding or sclerotherapy for the varices. [11] If this is sufficient then beta blockers and nitrates may be used for the prevention of re-bleeding. [11] If bleeding continues, balloon tamponade with a Sengstaken-Blakemore tube or Minnesota tube may be used in an attempt to mechanically compress the varices. [11] This may then be followed by a transjugular intrahepatic portosystemic shunt. [11] In those with cirrhosis, antibiotics decrease the chance of bleeding again, shorten the length of time spent in hospital, and decrease mortality. [5] Octreotide reduces the need for blood transfusions [29] and may decrease mortality. [30] No trials of vitamin K have been conducted. [31]

Blood products

The evidence for benefit of blood transfusions in GI bleed is poor with some evidence finding harm. [8] In those in shock O-negative packed red blood cells are recommended. [2] If large amounts of pack red blood cells are used additional platelets and fresh frozen plasma (FFP) should be administered to prevent coagulopathies. [4] In alcoholics FFP is suggested before confirmation of a coagulopathy due to presumed blood clotting problems. [2] Evidence supports holding off on blood transfusions in those who have a hemoglobin greater than 7 to 8 g/dL and moderate bleeding, including in those with preexisting coronary artery disease. [7] [10]

If the INR is greater than 1.5 to 1.8 correction with fresh frozen plasma or prothrombin complex may decrease mortality. [4] Evidence of a harm or benefit of recombinant activated factor VII in those with liver diseases and gastrointestinal bleeding is not determined. [32] A massive transfusion protocol may be used, but there is a lack of evidence for this indication. [14]

Procedures

The Blakemore esophageal balloon used for stopping esophageal bleeds if other measures have failed Sengstaken-Blakemore scheme EN.svg
The Blakemore esophageal balloon used for stopping esophageal bleeds if other measures have failed

The benefits versus risks of placing a nasogastric tube in those with upper GI bleeding are not determined. [4] Endoscopic evaluation within 24 hours is recommended, [4] in addition to medical management. [33] A number of endoscopic treatments may be used, including: epinephrine injection, band ligation, sclerotherapy, and fibrin glue depending on what is found. [2] Prokinetic agents such as erythromycin before endoscopy can decrease the amount of blood in the stomach and thus improve the operators view. [4] They also decrease the amount of blood transfusions required. [34] Early endoscopy decreases hospital and the amount of blood transfusions needed. [4] A second endoscopy within a day is routinely recommended by some [14] but by others only in specific situations. [20] Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found. [4] High and low dose PPIs appear equivalent at this point. [35] It is also recommended that people with high risk signs are kept in hospital for at least 72 hours. [4] Those at low risk of re-bleeding may begin eating typically 24 hours following endoscopy. [4] If other measures fail or are not available, esophageal balloon tamponade may be attempted. [2] While there is a success rate up to 90%, there are some potentially significant complications including aspiration and esophageal perforation. [2]

Colonoscopy is useful for the diagnosis and treatment of lower GI bleeding. [2] A number of techniques may be employed including clipping, cauterizing, and sclerotherapy. [2] Preparation for colonoscopy takes a minimum of six hours which in those bleeding briskly may limit its applicability. [36] Surgery, while rarely used to treat upper GI bleeds, is still commonly used to manage lower GI bleeds by cutting out the part of the intestines that is causing the problem. [2] Angiographic embolization may be used for both upper and lower GI bleeds. [2] Transjugular intrahepatic portosystemic shunting (TIPS) may also be considered. [14]

Prognosis

Death in those with a GI bleed is more commonly due to other illnesses (some of which may have contributed to the bleed, such as cancer or cirrhosis) than the bleeding itself. [2] Of those admitted to a hospital because of a GI bleed, death occurs in about 7%. [14] Despite treatment, re-bleeding occurs in about 7–16% of those with upper GI bleeding. [3] In those with esophageal varices, bleeding occurs in about 5–15% a year and if they have bled once, there is a higher risk of further bleeding within six weeks. [11] Testing and treating H. pylori if found can prevent re-bleeding in those with peptic ulcers. [4] The benefits versus risks of restarting blood thinners such as aspirin or warfarin and anti-inflammatories such as NSAIDs need to be carefully considered. [4] If aspirin is needed for cardiovascular disease prevention, it is reasonable to restart it within seven days in combination with a PPI for those with nonvariceal upper GI bleeding. [20]

Epidemiology

Gastrointestinal bleeding from the upper tract occurs in 50 to 150 per 100,000 adults per year. [8] It is more common than lower gastrointestinal bleeding which is estimated to occur at the rate of 20 to 30 per 100,000 per year. [2] Risk of bleeding is more common in males and increases with age. [2]

Related Research Articles

<span class="mw-page-title-main">Hematochezia</span> Medical condition

Haematochezia is the passage of fresh blood through the anus, usually in or with stools. The term is from Greek αἷμα ("blood") and χέζειν. Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper gastrointestinal bleed. The difference between hematochezia and rectorrhagia is that, in the latter, rectal bleeding is not associated with defecation; instead, it is associated with expulsion of fresh bright red blood without stools. The phrase bright red blood per rectum is associated with hematochezia and rectorrhagia.

<span class="mw-page-title-main">Upper gastrointestinal bleeding</span> Medical condition

Upper gastrointestinal bleeding is gastrointestinal bleeding (hemorrhage) in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock.

Hematemesis is the vomiting of blood. It can be confused with hemoptysis or epistaxis (nosebleed), which are more common. The source is generally the upper gastrointestinal tract, typically above the suspensory muscle of duodenum. It may be caused by ulcers, tumors of the stomach or esophagus, varices, prolonged and vigorous retching, gastroenteritis, ingested blood, or certain drugs.

Melena or melaena refers to the dark black, tarry feces that are associated with upper gastrointestinal bleeding. The black color and characteristic strong odor are caused by hemoglobin in the blood being altered by digestive enzymes and intestinal bacteria.

Coffee ground vomitus refers to a particular appearance of vomit. Within organic heme molecules of red blood cells is the element iron, which oxidizes following exposure to gastric acid. This reaction causes the vomitus to look like ground coffee.

<span class="mw-page-title-main">Fecal occult blood</span> Medical condition

Fecal occult blood (FOB) refers to blood in the feces that is not visibly apparent. A fecal occult blood test (FOBT) checks for hidden (occult) blood in the stool (feces).

<span class="mw-page-title-main">Esophageal varices</span> Medical condition

Esophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis. People with esophageal varices have a strong tendency to develop severe bleeding which left untreated can be fatal. Esophageal varices are typically diagnosed through an esophagogastroduodenoscopy.

<span class="mw-page-title-main">Dieulafoy's lesion</span> Medical condition

Dieulafoy's lesion is a medical condition characterized by a large tortuous artery most commonly in the stomach wall (submucosal) that erodes and bleeds. It can present in any part of the gastrointestinal tract. It can cause gastric hemorrhage but is relatively uncommon. It is thought to cause less than 5% of all gastrointestinal bleeds in adults. It was named after French surgeon Paul Georges Dieulafoy, who described this condition in his paper "Exulceratio simplex: Leçons 1-3" in 1898. It is also called "caliber-persistent artery" or "aneurysm" of gastric vessels. However, unlike most other aneurysms, these are thought to be developmental malformations rather than degenerative changes.

<span class="mw-page-title-main">Gastric varices</span> Medical condition

Gastric varices are dilated submucosal veins in the lining of the stomach, which can be a life-threatening cause of bleeding in the upper gastrointestinal tract. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis. Gastric varices may also be found in patients with thrombosis of the splenic vein, into which the short gastric veins that drain the fundus of the stomach flow. The latter may be a complication of acute pancreatitis, pancreatic cancer, or other abdominal tumours, as well as hepatitis C. Gastric varices and associated bleeding are a potential complication of schistosomiasis resulting from portal hypertension.

<span class="mw-page-title-main">Gastrointestinal disease</span> Medical condition

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

<span class="mw-page-title-main">Blood in stool</span> Medical condition

Blood in stool or rectal bleeding looks different depending on how early it enters the digestive tract—and thus how much digestive action it has been exposed to—and how much there is. The term can refer either to melena, with a black appearance, typically originating from upper gastrointestinal bleeding; or to hematochezia, with a red color, typically originating from lower gastrointestinal bleeding. Evaluation of the blood found in stool depends on its characteristics, in terms of color, quantity and other features, which can point to its source, however, more serious conditions can present with a mixed picture, or with the form of bleeding that is found in another section of the tract. The term "blood in stool" is usually only used to describe visible blood, and not fecal occult blood, which is found only after physical examination and chemical laboratory testing.

<span class="mw-page-title-main">Lower gastrointestinal bleeding</span> Medical condition

Lower gastrointestinal bleeding, commonly abbreviated LGIB, is any form of gastrointestinal bleeding in the lower gastrointestinal tract. LGIB is a common reason for seeking medical attention at a hospital's emergency department. LGIB accounts for 30–40% of all gastrointestinal bleeding and is less common than upper gastrointestinal bleeding (UGIB). It is estimated that UGIB accounts for 100–200 per 100,000 cases versus 20–27 per 100,000 cases for LGIB. Approximately 85% of lower gastrointestinal bleeding involves the colon, 10% are from bleeds that are actually upper gastrointestinal bleeds, and 3–5% involve the small intestine.

<span class="mw-page-title-main">Gastric antral vascular ectasia</span> Medical condition of the stomach

Gastric antral vascular ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anemia. The condition is associated with dilated small blood vessels in the pyloric antrum, which is a distal part of the stomach. The dilated vessels result in intestinal bleeding. It is also called watermelon stomach because streaky long red areas that are present in the stomach may resemble the markings on watermelon.

<span class="mw-page-title-main">Hemosuccus pancreaticus</span> Medical condition

Hemosuccus pancreaticus is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a bleeding source in the pancreas, pancreatic duct, or structures adjacent to the pancreas, such as the splenic artery, that bleed into the pancreatic duct, which is connected with the bowel at the duodenum, the first part of the small intestine. Patients with hemosuccus may develop symptoms of gastrointestinal hemorrhage, such as blood in the stools, maroon stools, or melena, which is a dark, tarry stool caused by digestion of red blood cells. They may also develop abdominal pain. It is associated with pancreatitis, pancreatic cancer and aneurysms of the splenic artery. Hemosuccus may be identified with endoscopy (esophagogastroduodenoscopy), where fresh blood may be seen from the pancreatic duct. Alternatively, angiography may be used to inject the celiac axis to determine the blood vessel that is bleeding. This may also be used to treat hemosuccus, as embolization of the end vessel may terminate the hemorrhage. However, a distal pancreatectomy—surgery to remove of the tail of the pancreas—may be required to stop the hemorrhage.

A stress ulcer is a single or multiple mucosal defect usually caused by physiological stress which can become complicated by upper gastrointestinal bleeding. These ulcers can be caused by shock, sepsis, trauma or other conditions and are found in patients with chronic illnesses. These ulcers are a significant issue in patients in critical and intensive care.

<span class="mw-page-title-main">Portal hypertensive gastropathy</span> Changes in the mucosa of the stomach in patients with portal hypertension

Portal hypertensive gastropathy refers to changes in the mucosa of the stomach in patients with portal hypertension; by far the most common cause of this is cirrhosis of the liver. These changes in the mucosa include friability of the mucosa and the presence of ectatic blood vessels at the surface. Patients with portal hypertensive gastropathy may experience bleeding from the stomach, which may uncommonly manifest itself in vomiting blood or melena; however, portal hypertension may cause several other more common sources of upper gastrointestinal bleeding, such as esophageal varices and gastric varices. On endoscopic evaluation of the stomach, this condition shows a characteristic mosaic or "snake-skin" appearance to the mucosa of the stomach.

Forrest classification is a classification of upper gastrointestinal hemorrhage used for purposes of comparison and in selecting patients for endoscopic treatment.

<span class="mw-page-title-main">Butyl cyanoacrylate</span> Chemical compound

n-Butyl cyanoacrylate, a cyanoacrylate ester, is a butyl ester of 2-cyano-2-propenoic acid. It is a colorless liquid with a sharp, irritating odor. It is insoluble in water. Its chief use is as the main component of medical cyanoacrylate glues. It can be encountered under various trade names, e.g. Cutseal, MediBond, MediCryl, PeriAcryl, GluStitch, Xoin, Gesika, VetGlu, Vetbond, LiquiVet, Indermil, LiquiBand, Histoacryl, IFABond, CutisSeal and others. The generic international nonproprietary name (INN) for NBCA is enbucrilate.

Therapeutic endoscopy is the medical term for an endoscopic procedure during which treatment is carried out via the endoscope. This contrasts with diagnostic endoscopy, where the aim of the procedure is purely to visualize a part of the gastrointestinal, respiratory or urinary tract in order to aid diagnosis. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding, or the finding of polyps during colonoscopy.

Hemostatic Powder Spray TC-325 is an inert, highly absorptive mineral agent which is used for the treatment of gastrointestinal bleeding. Applied during endoscopy to bleeding lesions, TC-325 is derived from bentonite, and is used to achieve hemostasis by absorbing water and creating a barrier that leads to mechanical tamponade (pressure) and concentration of clotting factors, resulting in enhanced coagulation. TC-325 was approved for gastrointestinal bleeding from causes other than gastric or esophageal varices. TC-325 results in immediate control of bleeding in 91-93% of cases. Technical success has gradually increased between 2011 and 2019, which may be due to device improvements or physician familiarity with the application of TC-325.

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  24. 1 2 Kanno, Takeshi; Yuan, Yuhong; Tse, Frances; Howden, Colin W.; Moayyedi, Paul; Leontiadis, Grigorios I. (2022-01-07). "Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding". The Cochrane Database of Systematic Reviews. 1 (1): CD005415. doi:10.1002/14651858.CD005415.pub4. ISSN   1469-493X. PMC   8741303 . PMID   34995368.
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