Gastrointestinal bleeding
Classification and external resources
ICD-10	K92.2
ICD-9	578.9
DiseasesDB	19317
MedlinePlus	003133
eMedicine	radio/301 radio/302 emerg/381
MeSH	D006471

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.

Contents 1 Symptoms and signs 2 Classification 2.1 Upper gastrointestinal bleeding 2.2 Lower gastrointestinal bleeding 3 Diagnosis 4 Treatment 4.1 Early management 4.2 Endoscopy 5 References

[edit] 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.

[edit] Classification

Gastrointestinal bleeding can be roughly divided into two clinical syndromes.

[edit] 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).

[edit] 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.

[edit] Diagnosis

Diagnosis is often based on direct observation of blood in the stool. This can be confirmed with a fecal occult blood test.

[edit] Treatment

[edit] 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.

[edit] 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.

[edit] References

• Ghosh S, Watts D, Kinnear M. Management of gastrointestinal haemorrhage. Postgrad Med J 2002;78:4-14. PMID 11796865.

v • d • e Digestive system · Digestive disease · Gastroenterology (primarily K20–K93, 530–579) Upper GI tract Esophagus Esophagitis (Candidal) · rupture (Boerhaave syndrome, Mallory-Weiss syndrome) · UES (Zenker's diverticulum) · LES (Barrett's esophagus) · Esophageal motility disorder (Nutcracker esophagus, Achalasia, Diffuse esophageal spasm, GERD) · Esophageal stricture · Megaesophagus Stomach Gastritis (Atrophic, Ménétrier's disease, Gastroenteritis) · Peptic (gastric) ulcer (Cushing ulcer, Dieulafoy's lesion) · Dyspepsia · Pyloric stenosis · Achlorhydria · Gastroparesis · Gastroptosis · Portal hypertensive gastropathy · Gastric antral vascular ectasia · Gastric dumping syndrome · Gastric volvulus Lower GI tract: Intestinal/ enteropathy Small intestine/ (duodenum/jejunum/ileum) Enteritis (Duodenitis, Jejunitis, Ileitis) — Peptic (duodenal) ulcer (Curling's ulcer) — Malabsorption: Coeliac · Tropical sprue · Blind loop syndrome · Whipple's · Short bowel syndrome · Steatorrhea · Milroy disease Large intestine (appendix/colon) Appendicitis · Colitis (Pseudomembranous, Ulcerative, Ischemic, Microscopic, Collagenous, Lymphocytic) · Functional colonic disease (IBS, Intestinal pseudoobstruction/Ogilvie syndrome) — Megacolon/Toxic megacolon · Diverticulitis/Diverticulosis Large and/or small Enterocolitis (Necrotizing) · IBD (Crohn's disease) — vascular: Abdominal angina · Mesenteric ischemia · Angiodysplasia — Bowel obstruction: Ileus · Intussusception · Volvulus · Fecal impaction — Constipation · Diarrhea (Infectious) Rectum Proctitis (Radiation proctitis) · Proctalgia fugax · Rectal prolapse Anus Anal fissure/Anal fistula · Anal abscess  · Anal dysplasia  · Pruritus ani GI bleeding/BIS Upper (Hematemesis, Melena) · Lower (Hematochezia) Accessory Liver Hepatitis (Viral hepatitis, Autoimmune hepatitis, Alcoholic hepatitis) · Cirrhosis (PBC) · Fatty liver (NASH) · vascular (Hepatic veno-occlusive disease, Portal hypertension, Nutmeg liver) · Alcoholic liver disease · Liver failure (Hepatic encephalopathy, Acute liver failure) · Liver abscess (Pyogenic, Amoebic) · Hepatorenal syndrome · Peliosis hepatis Gallbladder Cholecystitis · Gallstones/Cholecystolithiasis · Cholesterolosis · Rokitansky-Aschoff sinuses · Postcholecystectomy syndrome · Porcelain gallbladder Bile duct/ other biliary tree Cholangitis (PSC, Secondary sclerosing cholangitis, Ascending) · Cholestasis/Mirizzi's syndrome · Biliary fistula · Haemobilia · Gallstones/Cholelithiasis common bile duct (Choledocholithiasis, Biliary dyskinesia) · Sphincter of Oddi dysfunction Pancreatic Pancreatitis (Acute, Chronic, Hereditary) · Pancreatic pseudocyst · Exocrine pancreatic insufficiency · Pancreatic fistula Abdominopelvic Hernia Diaphragmatic: Congenital diaphragmatic · Hiatus — Abdominal hernia: Inguinal (Indirect, Direct) · Umbilical · Incisional · Femoral — Obturator hernia · Spigelian hernia · Internal hernia Peritoneal Peritonitis (Spontaneous bacterial peritonitis) · Hemoperitoneum · Pneumoperitoneum digestive system navs: anat of tract,glands,perit,diaphragm/physio/dev, noncongen/congen/congen of d+w/neoplasia, symptoms+signs/eponymous, proc

v • d • e Pathology: hemodynamics Decreases Thrombus/thrombosis Renal vein thrombosis Ischemia Brain ischemia · Ischaemic heart disease Infarction general: Anemic infarct · Hemorrhagic infarct regional: Myocardial infarction · Splenic infarction · Cerebral infarction Increases Hemorrhage general Bruise/Hematoma: Petechia · Purpura · Ecchymosis regional: head (Epistaxis, Hemoptysis, Intracranial hemorrhage, Hyphema) · torso (Hemothorax, Hemopericardium) · abdomen (Gastrointestinal bleeding, Haemobilia, Hemoperitoneum, Hematocele, Hematosalpinx ) · joint (Hemarthrosis) Edema general: Anasarca · Angioedema/Lymphedema · Exudate/Transudate regional: Cerebral edema · Pulmonary edema · Hydrothorax · Ascites/hydroperitoneum · Hydrosalpinx Other Hyperemia