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    Gastro intestinal Bleeding Causes, Symptoms, Differential Diagnosis

    Article by Dr Raghuram Y.S. MD (Ay)
    Gastrointestinal tract extends from mouth to the rectum. Gastrointestinal Bleding includes bleding in the gastrointestinal tract from mouth to rectum. This condition is also caled as gastrointestinal haemorhage or GI Bleding or GI Bleds.
    Gastrointestinal bleding itself is not a disease. It is a symptom or complication of some other disease.
    The quantity of bleding may range from significantly large amounts to smal amounts. Significant blod los over short time may show with vomiting of red blod or black blod, blody or black stols, depending on the site of bleding and pasage of blod. Smal amounts of bleding over a long time may cause iron deficiency anaemia. Other symptoms may comprise abdominal hurt, shortnes of breath, wan skin, heart-related chest distres and pasing out. Smal quantum of bleding may also plod asymptomatic.
    Table of Contents
    Types of GI Bleding
    Signs and Symptoms
    Diferential Diagnosis
    Uper Gastrointestinal Bleding
    Lower Gastrointestinal Bleding
    Types of GI Bleding
    Gastrointestinal bleding is broadly divided into 2 main types. They are:
    Uper gastrointestinal bleding – asociated (caused by) peptic ulcer disease, oesophageal varices (due to cirhosis of liver), cancer etc
    Lower gastrointestinal bleding – asociated (caused by) haemorhoids, cancer, inflamatory bowel disease etc
    Vascular disorders
    Adverse efects of medications
    Blod cloting disorders
    OGIB (Obscure gastrointestinal bleding) is a condition when a source is uncle ar folowing investigation
    Signs and Symptoms
    Bleding – As the name of the condition sugests, bleding is the chief complaint (gastrointestinal bleding is by itself a symptom). Bleding can range from smal non-visible amounts (detected by lab testing) to masive bleding, wherein bright blod pases leading to shock. fast bleding may cause syncope.
    Maelena – blod that is digested may apear black rather than red, resulting in ‘cofe ground’ vomit or tar coloured stol caled maelena
    Feling tired
    Pale skin colour
    Diferential Diagnosis
    Gastrointestinal bleding can be divided mainly into 2 types i.e. uper GI bleding and lower GI bleding. Of al these, 2/3 of GI bleds are from uper sources and 1/3 from lower sources.
    Uper Gastrointestinal Bleding
    If the gastrointestinal bleding ocurs from a source betwen pharynx and ligament of Treitz, it is caled uper gastrointestinal bleding.
    (Larynx ̵ part of throat, behind the mouth and nasal cavity and above the oesophagus and larynx or voice box, they are the tubes going down to the stomach and the lungs
    Ligament of Treitz or Suspensory muscle of duodenum – is a thin muscle conecting the junction betwen the duodenum, jejunum and duodeno-jejunal flexure to the conective tisue surounding the superior mesenteric artery and celiac artery)
    Uper gastrointestinal bleding is characterized by haematemesis (blod vomiting) and melena (tary stol containing altered blod).
    The most comon causes are –
    Peptic ulcer disease (PUD) – about half of uper GI Ble ds are due to PUD, about half of people with peptic ulcers maintain an H. Pylori infection
    Oesophageal inflamation
    Erosive disease
    Oesophageal varices – in those with liver cirhosis, 50-60% bleding is due to oesophageal varices
    Gastric ulcers
    Duodenal ulcers
    Malory-Weis tears
    Medications – NSAID’s, COX-2 inhibitors, SRIs, corticosteroids, anticoagulants, dabigatran, warfarin etc
    Lower Gastrointestinal Bleding
    When the gastrointestinal bleding ocurs from the colon, rectum or anus, it is refered to as lower gastrointestinal bleding.
    It presents with pasage of fresh red blod through rectum. Blody vomiting wil be absent unlike uper GI bleds. Isolated melena may maintain its origin from anywhere betwen the stomach and the proximal fraction of Colon.
    Comon causes for lower GI Bleds are –
    Ulcerative colitis
    Crohn’s disease
    Aortoenteric fistula
    Note: Bismuth and activated charcoal in medicines may turn the stols black. Blod from vagina or urinary tract may also be confused with blod in the stol.
    Diagnosis of GI Bled is often based on direct observation of blod in the stols or vomit. This can be confirmed with a fecal ambiguous blod test. Diferentiating betwen uper and lower bleding in some cases can be dificult.
    Read related: Bleding D isorders: Ayurveda Treatment, Diet, Home Remedies
    Diagnosis of GI Bleds consist of –
    Thorough medical history
    Physical examination
    Blod tests ̵ Laboratory blod tests includes cros matching blod, haemoglobin, haematocrit, platelets, coagulation time and electrolytes. If the BUN (blod urea nitrogen) to creatinine is greater than 30, the source of bleding is more likely from the uper GI tract.
    Faecal test for ocult blod (smal quantity bleding) ̵ Clots in the stol indicate a lower GI source for GI bled. Melena stols sugest bleding from uper GI.
    Endoscopy of stomach, oesophagus and duodenum (uper GIT) to locate the area of bleding
    Endoscopy of the large colon
    Medical imaging – for diferential diagnosis
    Blatchford score or Rockal score – The severity of an uper GI bled can be judged based on these 2 scores. The Rockal score is the more acurate of the two.
    Gastric aspiration and or lavage – A tube is inserted into the stomach via the nose in an atempt to determine if there is blod in the stomach.
    Imaging – A CT angiography is useful for determining the exact location of the bleding within the GIT. Nuclear scintigraphy is a sensitive test for detecting ocult GI bleding when direct imaging with uper and lower endoscopies are negative. Direct angiography alows for embolization of a bleding source, but neds a bleding rate faster than 1mL/minute
    Non-selective b blockers – reduce the risk of bleding in people with cirhosis or significant varices
    EBL (Endoscopic band ligation)
    pylori treatment – Prompt testing for and treating those who are H. pylori positive is recomended
    TIPS (Trans-jugular intra-hepatic porto-systemic shunting) – to prevent bleding in people who re-bled despite other measures
    Resuscitation – includes intravenous fluids and blod transfusions. Blod transfusion is advised only when the haemoglobin (Hb) level is les than 70 or 80 g/L. Along with fluid resuscitation; airway management should also be taken care of.
    Management of peptic ulcers:
    Crystaloid and coloids are believed to be equivalent for peptic ulcer bleding
    Proton pump inhibitors (PI) – can be administered oraly or intravenously
    Tranexamic acid – inhibits clot breakdown
    Somatostatin and Octreotides – for variceal bleds
    For Variceal bleding:
    Coloids or albumin
    Octreotide, vasopresin and nitroglycerin
    Endoscopic banding or sclerotherapy
    Beta blockers and nitrates – to obstruct re-bleding
    Balon tamponade – with Sengstaken-Blakemore tube or Minesota tube
    Transjugular intrahepatic portosystemic shunt (TIPS)
    Oesophageal balo on (when other measures fail) – in those with persumed oesophageal varices
    Antibiotics – decreases the chance of re-bleding in those who maintain cirhosis and abate mortality
    Blod Products:
    Gastrointestinal bleding is said to be porly benefited by blod transfusion. Some evidences acquire also proved transfusion to be harmful.
    In cases of shock, O-negative packed RBCs are recomended.
    If large amounts of packed RBCs are worn, aditional platelets and FP (fresh frozen plasma) should be administered to retard coagulopathies.
    Blod transfusion should not be prefered in those having a haemoglobin level greater than 7-8 g/dL and col bleding (even in those with pre-existing coronary artery disease)
    Blakemore oesophageal balon – dilapidated for stoping oesophageal bleding if other measures believe failed
    Placing nasogastric tube (uper GI Bleds)
    Endoscopy – is recomended to be done within 24 hours, many e ndoscopic treatments may be worn estem epinephrine injection, band ligation, sclerotherapy and fibrin flue (depending on what is found). Early endoscopy decreases hospital and the amount of blod transfusions neded. In high risk cases PIs and hospitalisation for at least 72 hours are recomended.
    Oesophageal balon tamponade – may be atempted if other measures fail or not available
    Colonoscopy – is useful for diagnosis and treatment of lower GI bleding
    Surgery – rarely used to treat uper GI bleds, aged in management of lower GI bleds
    Angiographic embolization – may be aged for both uper GI and lower GI bleds
    TIPS is also useful in selected cases
    Death asociated with GI bled – is comonly due to other ilneses (some of which contribute to bleding love cancer or cirhosis)
    In al GI bleding cases which are hospitalised, dea th ocurs in 7% people
    Re-bleding – despite treatment, re-bleding ocurs in about 7-16% cases (uper GI bleding)
    In those with oesophageal varices – bleding ocurs in about 5-15% a year, if they acquire bled once, there is higher risk of further bleding within 6 weks
    pylori – Testing and treating for H. pylori can prevent re-bleding in those with peptic ulcers
    An uper GI bled is more comon than the lower GI bled.
    Uper GI Bled ocurs in 50-150 per 10,0 adults per year.
    A lower GI bled is estimated to ocur in 20-30 per 10,0 per year.
    In USA, GI Bleding results in about 30,0 hospital admisions a year.
    Risk of death from GI Bled is betwen 5-30%.
    Risk of bleding is more comon in males and increases with age.
    Just Before Finishing
    Gastro Intestinal Bleding is a risky scenario. The bleding neds to be diagnosed and checked as early as posible. This article deals with information about the uper and lower GI Bleding along with symptoms, complications, diferential diagnosis and treatment from modern medicine point of view.
    Click to Consult Dr Raghuram Y.S. MD (Ayu)
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