GI bleeding

Definition

Gastrointestinal (GI) bleeding refers to bleeding arising from any location within the gastrointestinal tract. The GI tract includes the mouth, esophagus, stomach, small intestine (duodenum, jejunum, and ileum), large intestine (colon, rectum), and anus.

Description

GI bleeding is not a disease itself but a symptom of some underlying disease or condition. Gastrointestinal bleeding is divided into two general categories based on location of the source: upper GI bleeding (UGIB) from the esophagus, stomach, and duodenum, and lower GI bleeding (LGIB) from the remainder of the small intestine or the large intestine, including colon and rectum. Also, the underlying disease can be a chronic condition with bleeding that is not noticeable (occult bleeding) or an emergency situation with more profuse bleeding (overt bleeding or hemorrhage). GI bleeding is a common problem among older adults, with the majority of cases stemming from inflammation of the esophagus (esophagitis) or the stomach (gastritis), either of which may be associated with tissue erosion or ulcers.

Overt bleeding reveals itself by the vomiting of blood (hematemesis) or passage of blood through the anus. Vomited blood can be bright red, which indicates fresh bleeding anywhere from the mouth to the duodenum, or dark brown with coffee-ground consistency, which indicates that blood has had time to be partly digested in the stomach. Blood passed from the anus can be bright red or maroon, indicating new bleeding relatively close to the anus, or black, tarry bleeding (melena) that has been digested in the stomach or intestines after coming from a source higher in the GI system. The most severe GI bleeding usually occurs in adults with liver disease, due either to alcoholism or hepatitis , or in people with blood coagulation problems due to illness or certain medications. When severe bleeding results in significant loss of blood, the individual may go into shock with a dangerous drop in blood pressure and rapid heart rate. The person then may be confused and/or faint or may have chest pain (angina ), shortness of breath, or even a heart attack .

Chronic bleeding from any location in the GI tract is usually first detectable with tests of a stool specimen (occult blood test); a positive test indicates bleeding from either the upper or lower GI tract, thus not pinpointing the source. The patient may recall that stools have been somewhat dark. A red blood count may indicate anemia , reflecting loss of blood.

Demographics

Over 350,000 cases of upper GI bleeding are treated each year in the United States; from 35 to 45% are in adults over age 60, with a majority being women (60%). Total cases of lower GI bleeding are not known because not all are reported; however, approximately 25 of 100,000 individuals are hospitalized, with elderly individuals hospitalized 200 times as often as younger adults.

Causes and symptoms

Many conditions can cause GI bleeding in upper and lower portions of the GI tract. Major causes and percentages of upper GI bleeding, as reported in different studies, include:

• stomach ulcer (gastric ulcer), 5 to 43%
• ulcer in small intestine (duodenal ulcer or peptic ulcer), 6 to 42%
• inflammation of stomach (gastritis), 6 to 42%
• erosions (superficial ulcers) in stomach or small intestine (gastritis or duodenal erosions), 2 to 17%
• erosion of esophagus (erosive esophagitis), 2 to 15%
• esophageal bleeding (variceal bleeding or varices) common in liver disease, 1 to 20%
• tear in wall of stomach or intestine (Mallory-Weiss tear), 1 to 16%
• blood vessel swelling or tumor (angioma), 5 to 10%
• deformed vein or artery (arteriovenous malformation), less than 5%
• tumor in the GI tract (gastrointestinal tumor), less than 5%

Major causes of lower GI tract bleeding vary in frequency according to age, with inflammation and bleeding of small sacs in the intestine (diverticulitis ) being most common. Causes of lower GI bleeding in hospitalized patients include:

• small sacs (diverticula) in intestines (diverticulitis), 17 to 56%
• abnormal structure of veins or arteries (angiodysplasia or vascular ectasia), 3 to 30%
• polyps in the colon, 2 to 30%
• internal hemorrhoids, 3 to 28%
• anal fissure, less than 5%
• inflammation of the intestinal wall (colitis) caused by radiation, blockage, or infection, less than 5%
• cancer of the colon, less than 5%
• inflammatory bowel disease (ulcerative colitis or Crohn's disease), less than 5%

Other causes can be types of anemia that affect normal blood coagulation or drugs that affect coagulation such as aspirin , non-steroidal anti-inflammatory drugs (NSAIDs), and anti-coagulants, such as warfarin or heparin, sometimes given after heart attack or stroke . Hemorrhoids and colorectal cancer are the most frequent causes of minor bleeding in elderly adults. Ulcers, abnormal veins or arteries, and diverticulitis are causes of major bleeding in elderly adults.

The outstanding symptom of GI bleeding, regardless of cause, is the presence of bleeding, either occult or overt. Bowel movements may be red, black, only slightly dark, or may appear normal. Other symptoms and signs reflecting blood loss may include weakness, tiredness, or dizziness ; chest pain or shortness of breath with exertion; or a pale appearance of the skin or inner eyelid fold. Symptoms of the underlying problem, such as ulcer or cancer, may include pain or discomfort somewhere in the abdomen or belly, fever, or recent unexplained weight loss . Indications of a general bleeding problem may include frequent or unexplained bruising or prolonged bleeding from a minor injury.

Diagnosis

(bradycardia), resulting in unconsciousness (syncope). Vital signs may be unreliable indicators in elderly patients with severe GI bleeding because of underlying heart disease or other conditions.

Older individuals may have difficulty answering questions about recent and past history; a caretaker or family member may need to be present. If the patient is conscious, diagnosis may begin with questions about onset of bleeding, when and where it was noticed, character of the stool, and if the individual had any other symptoms prior to the bleeding such as fever or abdominal pain. Abdominal pain relieved on eating may indicate stomach ulcer as a cause. Weight loss might suggest GI tumor. The individual may be asked about recent travel to foreign countries and exposure to parasites, which can cause intestinal infection. The doctor will ask about previous GI bleeding; prior diagnosis of inflammatory bowel disease, liver disease, or abdominal tumor; use of therapeutic drugs or alcoholic beverages that may cause liver disease or prolonged bleeding; and prior anemia, high blood pressure or heart disease.

Physical examination includes measuring vital signs and examining the skin for pale appearance; large or small purplish areas where blood has leaked under the skin (ecchymosis or petechiae) are signs of blood disorders; and jaundice, a yellowish color of the skin, is a sign of liver disease. Other signs of liver disease could include redness (erythema) of the palms or small broken veins in the skin (spider angiomas). The physician will examine the heart and lungs, feel the abdomen for abnormal masses or size of the liver and spleen, and check the stool for the presence of blood. An enlarged liver or spleen could signify problems that could lead to bleeding.

Laboratory tests include a complete blood count to look for anemia or infection, and blood coagulation studies (platelet count, prothrombin time) to identify coagulation problems. Blood chemistries are done to find possible indicators of liver disease, heart disease, or other illnesses. Stool samples may be obtained to check for occult blood, which in older adults can be a sign of intestinal polyps or colon cancer . A urine sample is examined for blood.

Diagnostic procedures may include examining the upper intestinal tract with a lighted telescopic device (endoscope) with a tiny digital camera attached. The tube-like endoscope is passed through the nose or mouth and images can be viewed on a monitor as the procedure is performed. Examination of the lower intestinal tract may require colonoscopy , an endoscopic procedure performed with the same type of telescopic device, this time passed through the anus to examine the walls of the colon and rectum. These diagnostic procedures can also be therapeutic because a laser or electrical cauterizing device can be passed through the instrument, allowing bleeding sites to be viewed and repaired without open surgery. Capsule endoscopy is an effective type of diagnosis and treatment, allowing even the smallest erosions to be found in the intestines and treated as with other endoscopic methods described above.

QUESTIONS TO ASK YOUR DOCTOR

• If I have already had GI bleeding, will it likely happen again?
• How will I know if I'm bleeding internally?
• Do I have ulcers in my stomach or intestines?
• Is there something I can do to prevent my type of GI bleeding?
• What signs must I see before I call you?

Treatment

Shock is treated by restoring blood volume, giving either intravenous fluids such as saline or transfusions of blood or plasma. Correction of coagulation problems, if present, is essential and must be done quickly, possibly by giving vitamin K or special transfusions.

When bleeding sites are identified by endoscopic examination, treatment of the bleeding site may be done simultaneously, including electro- or laser-cauterization. Thermal coagulation methods that apply heat energy can also be used to stop bleeding, using either heater probes or electrical currents delivered by electrodes. Certain types of bleeding can also be stopped by injecting the bleeding site with solutions such as saline or diluted epinephrine. Applying hemostatic clips or rubber bands (mechanical treatment) can sometimes be used to seal the site while healing takes place. Sometimes surgery may be necessary.

Ulcers often require medical treatment. Drugs are typically used to cure infection by H. pylori organisms, a frequent cause of ulcers. Reduction of acid production in the stomach may be needed in some individuals with stomach ulcers or gastritis, giving high doses of drugs such as omeprazole either orally or intravenously in hospitalized patients, a treatment shown to be effective for patients who have upper GI bleeding. Combinations of treatments (medical, mechanical, endoscopic, and surgical) are often necessary.

Prognosis

GI bleeding stops by itself in most individuals (80%). The remaining 20% of individuals receive either cauterization of the bleeding site or surgical intervention to stop bleeding. Untreatable hemorrhage (when esophagus cannot be cleared of blood) or complications affecting heart rate, blood pressure, or coagulation are the leading causes of death , particularly in older individuals who already have advanced heart disease, high blood pressure, liver disease, or abnormal coagulation. Severe GI bleeding is more likely to result in complications in patients over age 85 due to their poorer response to continued bleeding and presence of other serious illnesses and physical changes common in aging. However, no significant differences are reported in number of deaths among younger or older adults with upper GI bleeding. Among adults with lower GI bleeding, death occurs in 4 to 10% of those over age 60, with risk of death shown to be greater among individuals with longer hospital stays, greater number of serious illnesses, and irregularities in heart rate, blood pressure, or coagulation.

Prevention

Preventing GI bleeding depends on preventing or treating common underlying conditions and diseases such as gastric or peptic ulcer, heart disease, high blood pressure, coagulation disorders, liver disease, and various types of anemia. Reducing stomach acid may help prevent bleeding ulcers. Prevention of bleeding hemorrhoids can be accomplished by correcting chronic constipation . Patients with any tendency toward upper GI bleeding or coagulation problems must avoid alcohol. Aspirin and non-steroidal anti-inflammatory drugs increase the likelihood of many forms of GI bleeding.

Caregiver concerns

An individual who has had GI bleeding of any kind may be subject to repeat episodes even if the underlying cause is being treated. A watchful attitude is needed to notice early signs of bleeding such as black or dark bowel movements, abdominal discomfort, weight loss, presence of bruises, or bleeding that will not stop when skin is broken, as well as complaints of feeling weak, exceptionally tired, or dizzy. Immediate treatment by medical professionals is also required if the individual appears pale, sweaty, or unusually confused, has chest pain or shortness of breath, or passes out.

KEY TERMS

Angiodysplasia —An abnormally formed collection of blood vessels anywhere in the walls of the gastrointestinal tract, but most common in the colon. It often bleeds.

Angioma —Tumor-like growth of blood vessels or related structures.

Cauterization —Use of a device that applies heat, cold, electricity, or chemical treatment to seal wounds or to burn or cut body tissues.

Diverticulitis —Inflammation of small sacs (diverticula) that form in the walls of the colon.

Ecchymosis —Large purple area of skin caused by leakage of blood under the skin, characteristic of certain blood clotting disorders.

Endoscopy —Use of a special tubular, telescopic instrument, to which a camera and surgical tools can be attached, to examine and treat the gastrointestinal tract or other hollow organs of the body.

Erosion —A wearing away of tissue, as by pressure or friction, as may occur to the inside lining walls of the esophagus or stomach.

Erythema —Skin that is red because of swelling of tiny veins in the skin called capillaries.

Fissure —Any deep slit in body tissue; anal fissure is a deep slit in the anus that can bleed.

Hematuria —Presence of blood in the urine.

Petechiae —Small purple spots on the skin caused by leakage of blood from tiny blood vessels; a sign of underlying blood or coagulation disorders.

Varices (singular, varix) —Enlarged (dilated) veins that are subject to bleeding.

Resources

BOOKS

Bjorkman, D. J. “Gastrointestinal Hemorrhage and Occult Gastrointestinal Bleeding.” Cecil Medicine, 23rd ed. Edited by L. Goldman. Philadelphia: Saunders, 2007.

Porter, R. S., ed. Merck Manual of Diagnosis and Therapy. White House Station, NJ: Merck Research Laboratories, 2007.

PERIODICALS

Tariq, S. H., and G. Mekhjian G. “Gastrointestinal Bleeding in Older Adults.” Clinics in Geriatric Medicine 23, no. 4 (2007): 23, no. 4 (2007).

OTHER

“Gastrointestinal Bleeding.” eMedicineHealth. August 10, 2005 [cited March 28, 2008]. http://www.emedicine-health.com>

ORGANIZATIONS

American Society for Gastrointestinal Endoscopy., 1520 Kensington Road, Oak Brook, IL, 60523, (630) 573-0600, www.asge.org.

National Institute for Diabetes, Digestive, and Kidney Diseases, 31 Center Drive MSC2560, Bldg. 31, Bethesda, MD, 20892-2560, (301) 496-3583, www2.niddk.nih.gov.

L. Lee Culvert