Gastrointestinal bleeding

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Overview
Gastrointestinal bleeding or gastrointestinal hemorrhage describes every form of hemorrhage (loss of blood) in the gastrointestinal tract, from the pharynx to the rectum. It has diverse causes, and a medical history, as well as physical examination, 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 and blood transfusion, treatment with proton pump inhibitors and occasionally with vasopressin analogues and tranexamic acid. Upper endoscopy or colonoscopy are generally considered appropriate to identify the source of bleeding and carry out therapeutic interventions.


 * Hematemesis is defined as vomiting blood (fresh blood, clots or "coffee grounds") and is usally due to a bleed in the upper GI tract
 * Melena refers to black, tarry stools and signals an upper GI bleed (blood has had time to be
 * Hematochezia refers to red, bloody stools and signals a lower GI bleed or brisk bleeding in the upper GI tract

Symptoms and signs
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), to massive bleeding where pure blood is passed and hypovolemia and shock may develop, risking death.

Classification
Gastrointestinal bleeding can be roughly divided into two clinical syndromes.

Upper gastrointestinal bleeding
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).

Lower gastrointestinal bleeding
Lower gastrointestinal bleeding may be indicated by red blood per rectum, especially in the absence of hematemesis. Isolated melena may originate from anywhere between the stomach and the proximal colon.

Main Causes

 * Diverticula
 * Hemorrhoid bleeding
 * Inflammatory colonic diseases
 * Ischemic colonic diseases
 * Tumors or polyps
 * Ulcerative diseases

Upper GI Bleeding

 * Angiodysplasia
 * Anticoagulant therapy
 * Arteriovenous malformation
 * Carcinoid tumor
 * Coagulopathy
 * Connective Tissue Disease
 * Cytomegalovirus (CMV)
 * Duodenal ulcer
 * Duodenal varices
 * Duodenum erosion
 * Epistaxis
 * Esophageal carcinoma
 * Esophageal ulcer
 * Esophageal varices
 * Gastric ulcer
 * Gastric carcinoma
 * Gastric varices
 * GI foreign bodies
 * Helicobacter pylori
 * Hemolytic Uremic Syndrome
 * Henoch-Schonlein Purpura
 * Hereditary Hemorrhagic Telangiectasia
 * Herpes
 * Ischemic Enteritis
 * Karposi's Sarcoma
 * Leukemia
 * Lower esophagus erosion
 * Lymphoma
 * Mallory-Weiss Tear
 * Metestatic tumor
 * Osler's Disease
 * Polyarteritis Nodosa
 * Rheumatoid Arteritis
 * Rheumatoid vasculitis
 * Small bowel carcinoma
 * Stomach erosion
 * Stomal ulcer
 * Systemic Lupus Erythematosus
 * Upper GI polyp
 * Uremia
 * Volvulus

Lower GI Bleeding

 * Amoeba
 * Anal fissure
 * Angiodysplasia
 * Angioma
 * Anorectal injuries
 * Aortoenteric Fistula
 * Behcet's Syndrome
 * Biopsy (secondary bleeding)
 * Campylobacter
 * Carcinoid tumors
 * Carcinoma
 * Colitis
 * Colon polyps
 * Colorectal carcinoma
 * Crohn's Disease
 * Diverticulosis
 * Familial adenomatous polyposis
 * Fissures
 * Foreign body
 * Gardner's Syndrome
 * Hemorrhoidal sclerotherapy or ligature
 * Hemorrhoids
 * Inflammatory Bowel Disease
 * Invagination
 * Ischemic colitis
 * Juvenile Polyposis
 * Lymphomas
 * Mechanical causes
 * Meckel's Diverticulum
 * Mesenteric Infarction
 * Peutz-Jegher's Syndrome
 * Polypectomy (secondary bleeding)
 * Polyps
 * Postoperative stitching
 * Proctitis
 * Prolapse of the rectum
 * Pseudomembranous Colitis]]
 * Radiation proctitis
 * Radiation colitis
 * Rectal ulcers
 * Salmonella
 * Shigella
 * Small bowel tumor
 * Strangulation
 * Telangiectasia
 * Trauma
 * Ulcerative colitis
 * Upper GI bleed
 * Varices
 * Vascular lesions
 * Vasculitis
 * Vibrio

Early management
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 may be administered.
 * Acid suppression: in an upper GI source, proton pump inhibitors reduce gastric acid production and enhance healing of bleeding lesions.
 * Inhibition of fibrinolysis: in ongoing bleeding, tranexamic acid reduces fibrinolysis and may decrease blood product requirements.
 * Correction of coagulopathy: if coagulation parameters (e.g. prothrombin time) are deranged, vitamin K or fresh frozen plasma may need to be administered.
 * Reduction of portal pressure: if the bleeding is thought to be due to esophageal varices (a complication of cirrhosis of the liver), vasopressin analogues and rarely octreotide may be administered. Rarely, a Sengstaken-Blakemore tube may be inserted to mechanically compress varices.
 * Urgent endoscopy: if the bleeding cannot be managed medically an urgent esophagogastroduodenoscopy (EGD/OGD) may identify sources of bleeding. This is a high-risk procedure best performed under safe circumstances in the intensive care unit or operating theatres.
 * Surgical intervention: in extreme cases of bleeding, laparotomy may be required to identify the bleeding source.

Endoscopy
After adequate stabilization, endoscopy (upper endoscopy and/or colonoscopy) are used to identify the source of bleeding. Injection, sclerotherapy, electrocoagulation, vascular clipping 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 therapy, presence of esophageal varices, adenomatous polyps and so on.