TREATMENTS &
RESEARCH

Search the
latest
treatment
information
here.

Dr. Huntley's
Diagnosis
Checklist

Have a symptom?
See what questions
a doctor would ask.
 

Causes of Gastrointestinal bleeding

Contents
  1. Gastrointestinal bleeding: Introduction
  2. List of Causes
  3. Drugs/substances (120 causes)
  4. Drug interaction (428 causes)
  5. Hidden causes
  6. Excerpts from book chapters
  7. Complication causes
  8. Causes of symptoms
  9. News
  10. Related cause information

List of causes of Gastrointestinal bleeding

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Gastrointestinal bleeding) that could possibly cause Gastrointestinal bleeding includes:

More causes: see full list of causes for Gastrointestinal bleeding

Causes of Gastrointestinal bleeding (Diseases Database):

The follow list shows some of the possible medical causes of Gastrointestinal bleeding that are listed by the Diseases Database:

Source: Diseases Database

Gastrointestinal bleeding Causes: Book Excerpts

Gastrointestinal bleeding as a complication of other conditions:

Other conditions that might have Gastrointestinal bleeding as a complication may, potentially, be an underlying cause of Gastrointestinal bleeding. Our database lists the following as having Gastrointestinal bleeding as a complication of that condition:

Gastrointestinal bleeding as a symptom:

Conditions listing Gastrointestinal bleeding as a symptom may also be potential underlying causes of Gastrointestinal bleeding. Our database lists the following as having Gastrointestinal bleeding as a symptom of that condition:

Medications or substances causing Gastrointestinal bleeding:

The following drugs, medications, substances or toxins are some of the possible causes of Gastrointestinal bleeding as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

See full list of 120 medications causing Gastrointestinal bleeding


Drug interactions causing Gastrointestinal bleeding:

When combined, certain drugs, medications, substances or toxins may react causing Gastrointestinal bleeding as a symptom.

The list below is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

  • Citalopram (Celexa) and Diclofenac (Voltaren) interaction
  • Citalopram (Celexa) and Diflunisal (Dolobid) interaction
  • Citalopram (Celexa) and Etodolac (Lodine) interaction
  • Citalopram (Celexa) and Fenoprofen (Nalfon) interaction
  • Citalopram (Celexa) and Flurbiprofen (Ansaid) interaction
  • more interactions...»

See full list of 428 drug interactions causing Gastrointestinal bleeding

Medical news summaries relating to Gastrointestinal bleeding:

The following medical news items are relevant to causes of Gastrointestinal bleeding:

Related information on causes of Gastrointestinal bleeding:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Gastrointestinal bleeding may be found in:

Causes of Gastrointestinal bleeding: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Gastrointestinal bleeding.

Hemorrhoids: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • External hemorrhoids
    –Located below the pectinate line
    –Typically painful
    • Internal hemorrhoids
      –Located above the pectinate line
      –Typically not painful, unless thrombosis
      occurs
    • Pregnancy
      –Up to 35% of pregnant females will develop hemorrhoids around the time of delivery, with most cases occurring after a vaginal delivery and/or a prolonged labor
  • Condylomata acuminatum (genital warts)
  • Rectal prolapse
    –External protrusion of the rectum
    –Complete prolapse versus partial full thickness prolapse versus prolapse of mucosa only
    –Partial rectal prolapse or mucosa-alone rectal prolapse is typically concentric, thus can be differentiated from internal prolapsing hemorrhoids that tend to have separation between cushions and inflammation
  • Rectal polyp
  • Rectal or anal cancer
  • Hypertrophied anal papilla (polypoid structure at pectinate line)
    • External skin tag
      –Redundant fold of tissue along the external anal margin
  • Perirectal abscess
  • Anal fissure or fistula
  • Rectal varices
    –Develop secondary to portal hypertension
  • Rectal cavernous hemangioma

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Rectal Pain: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Anal fissure
    –Acute fissure presents with pain and bleeding (noticed on toilet paper) immediately following defecation
    –Chronic fissure presents with long-standing itching and mild pain, with or without bleeding
  • Perianal abscess (with or without associated fistula formation
  • Thrombosed hemorrhoid
  • Levator ani syndrome
  • Proctalgia fugax (rectal muscle spasm)
  • Coccyodynia/coccygodynia
  • Fecal impaction
  • Neoplasm (rectal, pelvic, or cauda equina)
  • Idiopathic
  • Inflammatory bowel disease (ulcerative proctitis, Crohn's disease)
    • Solitary rectal ulcer syndrome
      –Misnomer: May be multiple, not restricted to rectum, and lesion may be polypoid
      –Neoplasm is a concern
    • Pruritus ani
    • Trauma
    • Anal sex
    • Constipation
    • Diarrhea
    • Less common causes (“zebras”) include familial rectal pain, endometriosis, pelvic inflammatory disease, prostatitis, myopathies, foreign bodies, and compression or inflammation of sacral nerves

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

GI Bleeding - Melena & Hematochezia: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Anatomic lesions
    –Diverticular bleeding causes 30–50% of all cases of massive rectal bleeding; associated with mild, crampy pain, but can be painless; not associated with diverticulitis
    –Meckel's diverticulum
  • Vascular lesions
    –Angiodysplasia (arteriovenous malformation): Most frequent cause in older patients; bleeding tends to be episodic and self-limited; painless; increased risk with increased age
  • Neoplastic lesions
    –Colon cancer or polyps: Causes 10% of cases of lower GI bleeding in patients >50 years; generally low-grade, recurrent bleeding
    –Rectal cancer
    –Small bowel tumors
  • Inflammatory lesions
    –Colitis/ulcers (e.g., inflammatory bowel disease, infectious colitis, ischemic colitis, radiation colitis)
    –Ischemic colitis generally presents with abdominal pain
    –Ulcerative colitis more associated with gross rectal bleeding
    –Crohn's disease more commonly associated with diffuse crampy abdominal pain, whereas ulcerative colitis is more localized to left lower quadrant
  • Anorectal lesions
    –Hemorrhoids are the most common cause of rectal bleeding in patients younger than 50 years old; usually painless bleeding
    –Fissures
    –Polyps
    –Idiopathic rectal ulcers
  • Aortoenteric fistula: Must be suspected in any patient with a known aortic graft (e.g., prior aortic aneurysm repair or occlusive aortic disease)
  • Idiopathic in up to 15% of cases
  • Upper GI bleeding
  • Systemic bleeding disorders (e.g., hemophilia, excessive anticoagulation, thrombocytopenia)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

GI Bleeding - Hematemesis: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Peptic ulcer disease is the most common etiology of upper GI bleeding
    –Increased risk with NSAID, steroid, or alcohol use; smoking, stress (e.g., ICU and trauma patients), or infections (Helicobacter pylori, CMV, herpes simplex virus)
  • Nasopharyngeal or oropharyngeal sources of bleeding
  • Esophageal etiologies
    –Esophageal varices (common in alcoholics and cirrhotic patients)
    –Erosive esophagitis: Infectious (e.g., Candida, HSV, CMV), corrosive ingestion, or pill-induced
    –Esophageal or gastric carcinoma
    –Esophageal or gastric polyps
  • Gastric etiologies
    –Gastric ulcer
    –Gastritis
    –Arteriovenous malformations: Osler-Weber-Rendu syndrome (cutaneous telangectasias, recurrent nosebleeds), idiopathic angiomas, radiation-induced telangectasias, blue rubber bleb nevus syndrome
    –Mallory-Weiss tear secondary to repetitive vomiting
    –Dieulafoy's lesion: Erosion of the mucosa overlying an artery in the stomach causes necrosis of the arterial wall and resultant hemorrhage
    –Gastric varices: Secondary to splenic vein thrombosis
    –Benign or malignant tumors
  • Duodenal etiologies
    –Duodenal ulcer
    –Erosion of a pancreatic tumor into the duodenum
    –Aortoenteric fistula: Must be suspected in any patient with a known aortic graft (e.g., prior AAA repair or occlusive aortic disease)
  • Systemic etiologies
    –Coagulopathies (e.g., hemophilia)
    –Thrombocytopenia
    –Anticoagulation therapy (e.g., warfarin)
    –Hereditary hemorrhagic telangiectasia
    –Leukemia
    –Connective tissue disease

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Hematochezia: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • Milk or soy protein allergy (colitis)
  • Anorectal fissure: passage of hard stool causing rectal trauma
  • Nectrotizing enterocolitis (NEC): Vast majority occur in premature infants
  • Infectious colitis
    –Bacterial: Salmonella, Shigella, Campylobacter, Yersinia, Clostridium difficile, and E. coli (O157:H7) –Parasitic: Entamoeba histolytica
    • Immunocompromised host
      –CMV enterocolitis
      –Disseminated aspergillosis
      –Mycobacterium avium complex
      –Typhlitis: Polymicrobial inflammation of the cecum associated with neutropenia
  • AIDS
    –Aphthous ulcerations of the intestine
    • Juvenile polyps
      –Most common source of significant rectal bleeding in childhood
      –Pathologically benign inflammatory polyps
  • Inflammatory bowel disease
  • Meckel diverticulum: Ectopic gastric mucosa, 2% of population
  • Intestinal duplication
  • Henoch-Schönlein purpura (HSP)
  • Lymphonodular hyperplasia
  • Solitary rectal ulcer
  • Ischemic injury
    –Malrotation with volvulus
    –Intussusception
    –Postoperative (colonic watershed regions)
    –Acute drug-induced ischemia (cocaine)
  • Hirschprung enterocolitis
  • Foreign body injury: Ingested glass, broken glass thermometer, other sharp objects
  • Munchausen syndrome by proxy
  • Vascular lesions
    –Hemangiomas (rare)
    –Arteriovenous, venous malformation
    –Klippel-Trenaunay syndrome
    –Blue rubber bleb nevus syndrome
    –Hereditary hemorrhagic telangiectasia
  • Hemorrhoids and colorectal varices from portal hypertension
    –Hemorrhoids rarely bleed in children

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Hematochezia: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anal fissure

Slight hematochezia characterizes anal fissure; blood may streak the stools or appear on toilet tissue Accompanying hematochezia is severe rectal pain that may make the patient reluctant to defecate, thereby causing constipation.

Angiodysplastic lesions

Most common in elderly patients, these arteriovenous lesions of the ascending colon typically cause chronic, bright red rectal bleeding Occasionally, this painless hematochezia may result in life-threatening blood loss and signs of shock, such as tachycardia and hypotension.

Coagulation disorders

Patients with a coagulation disorder (such as thrombocytopenia and disseminated intravascular coagulation) may experience GI bleeding marked by moderate to severe hematochezia

Bleeding may also occur in other body systems, producing such signs as epistaxis and purpura Associated findings vary with the specific coagulation disorder.

Colitis

Ischemic colitis commonly causes bloody diarrhea, especially in elderly patients Hematochezia may be slight or massive and is usually accompanied by severe, cramping lower abdominal pain and hypotension

Other effects include abdominal tenderness, distention, and absent bowel sounds. Severe colitis may cause life-threatening hypovolemic shock and peritonitis.

Ulcerative colitis typically causes bloody diarrhea that may also contain mucus. Hematochezia is preceded by mild to severe abdominal cramps and may cause slight to massive blood loss. Associated signs and symptoms include fever, tenesmus, anorexia, nausea, vomiting, hyperactive bowel sounds and, occasionally, tachycardia. Weight loss and weakness occur late.

Colon cancer

Bright red rectal bleeding with or without pain is a telling sign, especially in cancer of the left colon.

Usually, a left colon tumor causes early signs of obstruction, such as rectal pressure, bleeding, and intermittent fullness or cramping As the disease progresses, the patient also develops obstipation, diarrhea or ribbon-shaped stools, and pain, which is typically relieved by the passage of stools or flatus

Stools are grossly bloody.

Early tumor growth in the right colon may cause melena, abdominal aching, pressure, and dull cramps. As the disease progresses, the patient develops weakness and fatigue. Later, he may also experience diarrhea, anorexia, weight loss, anemia, vomiting, an abdominal mass, and signs of obstruction, such as abdominal distention and abnormal bowel sounds.

Colorectal polyps

Colorectal polyps are the most common cause of intermittent hematochezia in adults younger than age 60; however, sometimes such polyps produce no symptoms When located high in the colon, polyps may cause blood-streaked stools

The stools yield a positive response when tested with guaiac. If the polyps are located closer to the rectum, they may bleed freely.

Diverticulitis

Most common in the elderly patient, diverticulitis can suddenly cause mild to moderate rectal bleeding after the patient feels the urge to defecate The bleeding may end abruptly or may progress to life-threatening blood loss with signs of shock

Associated signs and symptoms may include left lower quadrant pain that’s relieved by defecation, alternating episodes of constipation and diarrhea, anorexia, nausea and vomiting, rebound tenderness, and a distended tympanic abdomen.

Dysentery

Bloody diarrhea is common in infection with Shigella, Amoeba, and Campylobacter, but rare with Salmonella

Abdominal pain or cramps, tenesmus, a fever, and nausea may also occur.

Esophageal varices (ruptured)

In esophageal varices, a life-threatening disorder, hematochezia may range from slight rectal oozing to grossly bloody stools and may be accompanied by mild to severe hematemesis or melena This painless but massive hemorrhage may precipitate signs of shock, such as tachycardia and hypotension

In fact, signs of shock occasionally precede overt signs of bleeding. Typically, the patient has a history of chronic liver disease.

Food poisoning (staphylococcal)

The patient may have bloody diarrhea 1 to 6 hours after ingesting food toxins Accompanying signs and symptoms include severe, cramping abdominal pain; nausea and vomiting; and prostration, all of which last a few hours.

Hemorrhoids

Hematochezia may accompany external hemorrhoids, which typically cause painful defecation, resulting in constipation Less painful internal hemorrhoids usually produce more chronic bleeding with bowel movements, which may eventually lead to signs of anemia, such as weakness and fatigue.

Leptospirosis

The severe form of leptospirosis  — Weil’s syndrome — produces hematochezia or melena along with other signs of bleeding, such as epistaxis and hemoptysis

The bleeding is typically preceded by a sudden frontal headache and severe thigh and lumbar myalgia that may be accompanied by cutaneous hyperesthesia Conjunctival suffusion is indicative

Bleeding is followed by chills, a rapidly rising fever and, perhaps, nausea and vomiting. A fever, a headache, and myalgia usually intensify and persist for weeks. Other findings may include right upper quadrant tenderness, hepatomegaly, and jaundice.

Peptic ulcer

Upper GI bleeding is a common complication in peptic ulcer The patient may display hematochezia, hematemesis, or melena, depending on the rapidity and amount of bleeding

If the peptic ulcer penetrates an artery or vein, massive bleeding may precipitate signs of shock, such as hypotension and tachycardia. Other findings may include chills, a fever, nausea and vomiting, and signs of dehydration, such as dry mucous membranes, poor skin turgor, and thirst. The patient typically has a history of epigastric pain that’s relieved by foods or antacids; he may also have a history of habitually using tobacco, alcohol, or NSAIDs.

Ulcerative proctitis

Ulcerative proctitis typically causes an intense urge to defecate, but the patient passes only bright red blood, pus, or mucus Other common signs and symptoms include acute constipation and tenesmus.

Other causes

Tests

Certain procedures, especially colonoscopy, polypectomy, and proctosigmoidoscopy, may cause rectal bleeding Bowel perforation is rare.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Melena: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Colon cancer

On the right side of the colon, early tumor growth may cause melena accompanied by abdominal aching, pressure, or cramps. As the disease progresses, the patient develops weakness, fatigue, and anemia. Eventually, he also experiences diarrhea or obstipation, anorexia, weight loss, vomiting, and other signs and symptoms of intestinal obstruction.

With a tumor on the left side, melena is a rare sign until late in the disease. Early tumor growth commonly causes rectal bleeding with intermittent abdominal fullness or cramping and rectal pressure. As the disease progresses, the patient may develop obstipation, diarrhea, or pencil-shaped stools. At this stage, bleeding from the colon is signaled by melena or bloody stools.

Ebola virus

Melena, hematemesis, and bleeding from the nose, gums, and vagina may occur later with Ebola virus. Patients usually report an abrupt onset of a headache, malaise, myalgia, a high fever, diarrhea, abdominal pain, dehydration, and lethargy on the fifth day of illness. Pleuritic chest pain, a dry hacking cough, and pharyngitis have also been noted. A maculopapular rash develops between days 5 and 7 of the illness.

Esophageal cancer

Melena is a late sign of esophageal cancer, a malignant neoplastic disease that’s three times more common in men than in women. Increasing obstruction first produces painless dysphagia, then rapid weight loss. The patient may experience steady chest pain with substernal fullness, nausea, vomiting, and hematemesis. Other findings include hoarseness, a persistent cough (possibly hemoptysis), hiccups, a sore throat, and halitosis. In the later stages, signs and symptoms include painful dysphagia, anorexia, and regurgitation.

Esophageal varices (ruptured)

Ruptured esophageal varices is a life-threatening disorder that can produce melena, hematochezia, and hematemesis. Melena is preceded by signs of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. Agitation or confusion signals developing hepatic encephalopathy.

Gastritis

Melena and hematemesis are common. The patient may also experience mild epigastric or abdominal discomfort that’s exacerbated by eating, belching, nausea, vomiting, and malaise.

Mallory-Weiss syndrome

Mallory-Weiss syndrome is characterized by massive bleeding from the upper GI tract due to a tear in the mucous membrane of the esophagus or the junction of the esophagus and the stomach. Melena and hematemesis follow vomiting. Severe upper abdominal bleeding leads to signs and symptoms of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. The patient may also report epigastric or back pain.

Mesenteric vascular occlusion

Mesenteric vascular occlusion is a life-threatening disorder that produces slight melena with 2 to 3 days of persistent, mild abdominal pain. Later, abdominal pain becomes severe and may be accompanied by tenderness, distention, guarding, and rigidity. The patient may also experience anorexia, vomiting, a fever, and profound shock.

Peptic ulcer

Melena may signal life-threatening hemorrhage from vascular penetration. The patient may also develop decreased appetite, nausea, vomiting, hematemesis, hematochezia, and left epigastric pain that’s gnawing, burning, or sharp and may be described as heartburn or indigestion. With hypovolemic shock come tachycardia, tachypnea, hypotension, dizziness, syncope, and cool, clammy skin.

Small-bowel tumors

Small-bowel tumors may bleed and produce melena. Other signs and symptoms include abdominal pain, distention, and an increasing frequency and pitch of bowel sounds.

Thrombocytopenia

Melena or hematochezia may accompany other manifestations of bleeding tendency: hematemesis, epistaxis, petechiae, ecchymoses, hematuria, vaginal bleeding, and characteristic blood-filled oral bullae. Typically, the patient displays malaise, fatigue, weakness, and lethargy.

Typhoid fever

Melena or hematochezia occurs late in typhoid fever and may occur with hypotension and hypothermia. Other late findings include mental dullness or delirium, marked abdominal distention and diarrhea, marked weight loss, and profound fatigue.

Yellow fever

Melena, hematochezia, and hematemesis are ominous signs of hemorrhage, a classic feature, which occurs along with jaundice. Other findings include a fever, a headache, nausea, vomiting, epistaxis, albuminuria, petechiae and mucosal hemorrhage, and dizziness.

Other causes

Drugs and alcohol

Aspirin, other nonsteroidal anti-inflammatory drugs, or alcohol can cause melena as a result of gastric irritation.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Rectal pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Abscess (perirectal)

A perirectal abscess can occur in various locations in the rectum and anus, causing pain in the perianal area. Typically, a superficial abscess produces constant, throbbing local pain that’s exacerbated by sitting or walking. The local pain associated with a deeper abscess may begin insidiously, commonly high in the rectum or even in the lower abdomen, and is accompanied by an indurated anal mass. The patient may also develop associated signs and symptoms, such as a fever, malaise, anal swelling and inflammation, purulent drainage, and local tenderness.

Anal fissure

An anal fissure is a longitudinal crack in the anal lining that causes sharp rectal pain on defecation. The patient typically experiences a burning sensation and gnawing pain that can continue up to 4 hours after defecation. Fear of provoking this pain may lead to acute constipation. The patient may also develop anal pruritus and extreme tenderness and may report finding spots of blood on the toilet tissue after defecation.

Anorectal fistula

Pain develops when a tract formed between the anal canal and skin temporarily seals. It persists until drainage resumes. Other chief complaints include pruritus and drainage of pus, blood, mucus and, occasionally, stool.

Hemorrhoids

Thrombosed or prolapsed hemorrhoids cause rectal pain that may worsen during defecation and abate after it. The patient’s fear of provoking the pain may lead to constipation. Usually, rectal pain is accompanied by severe itching. Internal hemorrhoids may also produce mild, intermittent bleeding that characteristically occurs as spotting on the toilet tissue or on the stool surface. External hemorrhoids are visible outside the anal sphincter.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Vaginal bleeding, postmenopausal: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Atrophic vaginitis

When bloody staining occurs, it usually follows coitus or douching. Characteristic white, watery vaginal discharge may be accompanied by pruritus, dyspareunia, and a burning sensation in the vagina and labia. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Cervical cancer

Early invasive cervical cancer causes vaginal spotting or heavier bleeding, usually after coitus or douching but occasionally spontaneously. Related findings include persistent, pink-tinged, and foul-smelling vaginal discharge and postcoital pain. As the cancer spreads, back and sciatic pain, leg swelling, anorexia, weight loss, hematuria, dysuria, rectal bleeding, and weakness may occur.

Cervical or endometrial polyps

Cervical or endometrial polyps are small, pedunculated growths that may cause spotting (possibly as a mucopurulent, pink discharge) after coitus, douching, or straining to defecate. Many endometrial polyps are asymptomatic, however.

Endometrial hyperplasia or cancer

Bleeding occurs early, can be brownish and scant or bright red and profuse, and usually follows coitus or douching. Bleeding later becomes heavier and more frequent, leading to clotting and anemia. Bleeding may be accompanied by pelvic, rectal, lower back, and leg pain. The uterus may be enlarged.

Ovarian tumors (feminizing)

Estrogen-producing ovarian tumors can stimulate endometrial shedding and cause heavy bleeding unassociated with coitus or douching. A palpable pelvic mass, increased cervical mucus, breast enlargement, and spider angiomas may be present.

Vaginal cancer

Characteristic spotting or bleeding may be preceded by a thin, watery vaginal discharge. Bleeding may be spontaneous but usually follows coitus or douching. A firm, ulcerated vaginal lesion may be present; dyspareunia, urinary frequency, bladder and pelvic pain, rectal bleeding, and vulvar lesions may develop later.

Other causes

Drugs

Unopposed estrogen replacement therapy is a common cause of abnormal vaginal bleeding. This can usually be reduced by adding progesterone (in women who haven’t had a hysterectomy) and by adjusting the patient’s estrogen dosage.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Hemorrhoids: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Hemorrhoids probably result from increased venous pressure in the hemorrhoidal plexus. Predisposing factors include occupations that require prolonged standing or sitting; straining due to constipation, diarrhea, coughing, sneezing, or vomiting; heart failure; hepatic disease, such as cirrhosis, amebic abscesses, or hepatitis; alcoholism; anorectal infections; loss of muscle tone due to old age, rectal surgery, or episiotomy; anal intercourse; and pregnancy.

Hemorrhoids are more common in whites, in persons of higher socioeconomic classes, and in persons who live in rural areas. However, actual incidence figures are unknown because many patients with hemorrhoids self-medicate.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Postmenopausal bleeding: Causes
(Professional Guide to Diseases (Eighth Edition))

Postmenopausal bleeding may result from:

❑ exogenous estrogen, when administration is excessive or prolonged or when small amounts are given in the presence of a hypersensitive endometrium

❑ endogenous estrogen production, especially when levels are high, as in persons with estrogen-producing ovarian tumor; however, in some persons, even a slight fluctuation in estrogen levels may cause bleeding

❑ atrophic endometrium due to low estrogen levels

❑ atrophic vaginitis, usually triggered by trauma during coitus in the absence of estrogen production

❑ aging, which increases vascular vulnerability by thinning epithelial surfaces, increasing vascular fragility, producing degenerative tissue changes, and decreasing resistance to infections

❑ cervical or endometrial cancer (more common after age 60)

❑ adenomatous hyperplasia or atypical adenomatous hyperplasia (usually considered a premalignant lesion).

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Melena: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Colon cancer

On the right side of the colon, early tumor growth may cause melena accompanied by abdominal aching, pressure, or cramps. As the disease progresses, the patient develops weakness, fatigue, and anemia. Eventually, he also experiences diarrhea or obstipation, anorexia, weight loss, vomiting, and other signs and symptoms of intestinal obstruction.

With a tumor on the left side, melena is a rare sign until late in the disease. Early tumor growth commonly causes rectal bleeding with intermittent abdominal fullness or cramping and rectal pressure. As the disease progresses, the patient may develop obstipation, diarrhea, or pencil-shaped stools. At this stage, bleeding from the colon is signaled by melena or bloody stools.

Ebola virus

Melena, hematemesis, and bleeding from the nose, gums, and vagina may occur later with this disorder. Patients usually report abrupt onset of headache, malaise, myalgia, high fever, diarrhea, abdominal pain, dehydration, and lethargy on the fifth day of illness. Pleuritic chest pain, dry hacking cough, and pharyngitis have also been noted. A maculopapular rash develops between days 5 and 7 of the illness.

Esophageal cancer

Melena is a late sign of this malignant neoplastic disease that’s three times more common in men than women. Increasing obstruction first produces painless dysphagia, then rapid weight loss. The patient may experience steady chest pain with substernal fullness, nausea, vomiting, and hematemesis. Other findings include hoarseness, persistent cough (possibly hemoptysis), hiccups, sore throat, and halitosis. In the later stages, signs and symptoms include painful dysphagia, anorexia, and regurgitation.

Esophageal varices (ruptured)

This life-threatening disorder can produce melena, hematochezia, and hematemesis. Melena is preceded by signs of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. Agitation or confusion signals developing hepatic encephalopathy.

Gastric cancer

Melena and altered bowel habits may occur late with this uncommon cancer. More common findings include insidious onset of upper abdominal or retrosternal discomfort and chronic dyspepsia, which are unrelieved by antacids and exacerbated by food. Anorexia and slight nausea often occur, along with hematemesis, pallor, fatigue, weight loss, and a feeling of abdominal fullness.

Gastritis

Melena and hematemesis are common. The patient may also experience mild epigastric or abdominal discomfort that’s exacerbated by eating; belching; nausea; vomiting; and malaise.

Malaria

Melena may accompany persistent high fever and orthostatic hypotension in severe malaria. Other features include hemoptysis, vomiting, abdominal pain, diarrhea, oliguria, and headache, seizures, delirium, or coma. These findings are interspersed throughout the malarial paroxysm—chills, then high fever, and then profuse diaphoresis.

Mallory-Weiss syndrome

This condition is characterized by massive bleeding from the upper GI tract due to a tear in the mucous membrane of the esophagus or the junction of the esophagus and the stomach. Melena and hematemesis follow vomiting. Severe upper abdominal bleeding leads to signs and symptoms of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. The patient may also report epigastric or back pain.

Mesenteric vascular occlusion

This life-threatening disorder produces slight melena with 2 to 3 days of persistent, mild abdominal pain. Later, abdominal pain becomes severe and may be accompanied by tenderness, distention, guarding, and rigidity. The patient may also experience anorexia, vomiting, fever, and profound shock.

Peptic ulcer

Melena may signal life-threatening hemorrhage from vascular penetration. The patient may also develop decreased appetite, nausea, vomiting, hematemesis, hematochezia, and left epigastric pain that’s gnawing, burning, or sharp and may be described as heartburn or indigestion. With hypovolemic shock come tachycardia, tachypnea, hypotension, dizziness, syncope, and cool, clammy skin.

Small-bowel tumors

These tumors may bleed and produce melena. Other signs and symptoms include abdominal pain, distention, and increasing frequency and pitch of bowel sounds.

Thrombocytopenia

Melena or hematochezia may accompany other manifestations of bleeding tendency: hematemesis, epistaxis, petechiae, ecchymoses, hematuria, vaginal bleeding, and characteristic blood-filled oral bullae. Typically, the patient displays malaise, fatigue, weakness, and lethargy.

Typhoid fever

Melena or hematochezia occurs late in this disorder and may occur with hypotension and hypothermia. Other late findings include mental dullness or delirium, marked abdominal distention and diarrhea, marked weight loss, and profound fatigue.

Yellow fever

Melena, hematochezia, and hematemesis are ominous signs of hemorrhage, a classic feature, which occurs along with jaundice. Other findings include fever, headache, nausea, vomiting, epistaxis, albuminuria, petechiae and mucosal hemorrhage, and dizziness.

Other causes

Drugs and alcohol

Aspirin, other nonsteroidal anti-inflammatories, or alcohol can cause melena as a result of gastric irritation.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Rectal pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abscess (perirectal)

This abscess can occur in various locations in the rectum and anus, causing pain in the perianal area. Typically, a superficial abscess produces constant, throbbing local pain that’s exacerbated by sitting or walking. The local pain associated with a deeper abscess may begin insidiously, often high in the rectum or even in the lower abdomen, and is accompanied by an indurated anal mass. The patient may also develop associated signs and symptoms, such as fever, malaise, anal swelling and inflammation, purulent drainage, and local tenderness.

Abscess (prostatic)

This disorder occasionally produces rectal pain. Common associated findings include urine retention and frequency, dysuria, and fever. A rectal examination may reveal prostatic tenderness and gas.

Anal fissure

This longitudinal crack in the anal lining causes sharp rectal pain on defecation. The patient typically experiences a burning sensation and gnawing pain that can continue up to 4 hours after defecation. Fear of provoking this pain may lead to acute constipation. The patient may also develop anal pruritus and extreme tenderness and may report finding spots of blood on the toilet tissue after defecation.

Anorectal fistula

Pain develops when a tract formed between the anal canal and skin temporarily seals. It persists until drainage resumes. Other chief complaints include pruritus and drainage of pus, blood, mucus, and occasionally stool.

Cryptitis

This disorder results when particles of stool that are lodged in the anal folds decay and cause infection, which may produce dull anal pain or discomfort and anal pruritus.

Hemorrhoids

Thrombosed or prolapsed hemorrhoids cause rectal pain that may worsen during defecation and abate after it. The patient’s fear of provoking the pain may lead to constipation. Usually, rectal pain is accompanied by severe itching. Internal hemorrhoids may also produce mild, intermittent bleeding that characteristically occurs as spotting on the toilet tissue or on the stool surface. External hemorrhoids are visible outside the anal sphincter.

Proctalgia fugax

With this disorder, muscle spasms of the rectum and pelvic floor produce sudden, severe episodes of rectal pain that last up to several minutes and then disappear. The patient may report being awakened by the pain, which is sometimes associated with stress or anxiety and relieved by food and drink.

Rectal cancer

Rectal pain, bleeding, tenesmus, and a hard, nontender mass are typical findings in this rare form of cancer.

Other causes

Anal intercourse

Shearing forces may cause inflammation or tearing of the mucous membranes and discomfort.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Hematochezia [Rectal bleeding]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Amyloidosis

Hematochezia occasionally occurs when this disorder affects the GI tract. Massive, rapid hematochezia may precipitate signs of shock, such as hypotension and tachycardia. Associated signs and symptoms include hypoactive or absent bowel sounds, abdominal pain, malabsorption, diarrhea, and renal disease. The patient may also have a stiff, enlarged tongue, resulting in dysarthria.

Anal fissure

Slight hematochezia characterizes this disorder; blood may streak the stools or appear on toilet tissue. Accompanying hematochezia is severe rectal pain that may make the patient reluctant to defecate, thereby causing constipation.

Angiodysplastic lesions

Most common in elderly patients, these arteriovenous lesions of the ascending colon typically cause chronic, bright red rectal bleeding. Occasionally, they may result in life-threatening blood loss and signs of shock, such as tachycardia and hypotension.

Anorectal fistula

Blood, pus, mucus, and occasionally stools may drain from this type of fistula. Other effects include rectal pain and pruritus.

Coagulation disorders

Patients with a coagulation disorder (such as thrombocytopenia or disseminated intravascular coagulation) may experience GI bleeding marked by moderate to severe hematochezia. Bleeding may also occur in other body systems, producing such signs as epistaxis and purpura. Associated findings vary with the specific coagulation disorder.

Colitis

Ischemic colitis commonly causes bloody diarrhea, especially in elderly patients. Rectal bleeding may be slight or massive and is usually accompanied by severe, cramping lower abdominal pain and hypotension. Other effects include abdominal tenderness, distention, and absent bowel sounds. Severe colitis may cause life-threatening hypovolemic shock and peritonitis.

Ulcerative colitis typically causes bloody diarrhea that may also contain mucus. Blood loss may be slight or massive and is preceded by mild to severe abdominal cramps. Associated signs and symptoms include fever, tenesmus, anorexia, nausea, vomiting, hyperactive bowel sounds and, occasionally, tachycardia. Weight loss and weakness occur late.

Colon cancer

Bright red rectal bleeding with or without pain is a telling sign, especially in cancer of the left colon. This type of tumor usually causes early signs of obstruction, such as rectal pressure, bleeding, and intermittent fullness or cramping. As the disease progresses, the patient also develops obstipation, diarrhea or ribbon-shaped stools, and pain that’s typically relieved by passage of stools or flatus. Stools are grossly bloody.

Cancer of the right colon may initially cause melena and abdominal aching, pressure, and dull cramps. As the disease progresses, the patient may also experience diarrhea, anorexia, weight loss, anemia, weakness and fatigue, vomiting, an abdominal mass, and signs of obstruction, such as abdominal distention and abnormal bowel sounds.

Colorectal polyps

These polyps are the most common cause of intermittent hematochezia in adults younger than age 60, but they don’t always produce symptoms. When located high in the colon, polyps may cause blood-streaked stools that yield a positive response when tested with guaiac. If the polyps are located closer to the rectum, they may bleed freely.

Crohn’s disease

Hematochezia is not a common sign of this disorder unless the perineum is involved. If rectal bleeding does occur, it’s likely to be massive. The chief clinical features of Crohn’s disease include fever, abdominal distention and pain with guarding, diarrhea, hyperactive bowel sounds, anorexia, nausea, and fatigue. Palpation may reveal a mass in the colon.

Diverticulitis

Most common in elderly patients, this disorder can suddenly cause mild to moderate rectal bleeding after the patient feels the urge to defecate. The bleeding may end abruptly or may progress to life-threatening blood loss with signs of shock. Associated signs and symptoms may include left-lower-quadrant pain that’s relieved by defecation, alternating episodes of constipation and diarrhea, anorexia, nausea and vomiting, rebound tenderness, and a distended tympanic abdomen.

Dysentery

Bloody diarrhea is common in infection with Shigella, Amoeba, and Campylobacter, but rare with Salmonella. Abdominal pain or cramps, tenesmus, fever, and nausea may also occur.

Esophageal varices (ruptured)

In this life-threatening disorder, hematochezia may range from slight rectal oozing to grossly bloody stools and may be accompanied by mild to severe hematemesis or melena. Signs of shock, such as tachycardia and hypotension, may follow or occasionally precede overt signs of bleeding. Typically, the patient has a history of chronic liver disease.

Food poisoning (staphylococcal)

The patient may have bloody diarrhea 1 to 6 hours after ingesting food toxins. Accompanying signs and symptoms, which last a few hours, include severe, cramping abdominal pain, nausea and vomiting, and prostration.

Hemorrhoids

Hematochezia may accompany external hemorrhoids, which typically cause painful defecation, resulting in constipation. Less painful internal hemorrhoids usually produce more chronic bleeding with bowel movements, which may eventually lead to signs of anemia, such as weakness and fatigue.

Leptospirosis

The severe form of this infection—Weil’s syndrome—produces hematochezia or melena along with other signs of bleeding, such as epistaxis and hemoptysis. The bleeding is typically preceded by a sudden frontal headache, severe thigh and lumbar myalgia, cutaneous hyperesthesia, and conjunctival suffusion. Bleeding is followed by chills, a rapidly rising fever, and perhaps nausea and vomiting. Fever, headache, and myalgia usually intensify and persist for weeks. Other findings may include right-upper-quadrant tenderness, hepatomegaly, and jaundice.

Peptic ulcer

Upper GI bleeding is a common complication in this disorder. The patient may display hematochezia, hematemesis, or melena, depending on the intensity and amount of bleeding. If the peptic ulcer penetrates an artery or vein, massive bleeding may precipitate signs of shock, such as hypotension and tachycardia. Other findings may include chills, fever, nausea and vomiting, and signs of dehydration, such as dry mucous membranes, poor skin turgor, and thirst. Most patients have a history of epigastric pain that’s relieved by foods or antacids; some also have a history of habitual use of tobacco, alcohol, or nonsteroidal anti-inflammatory drugs.

Rectal melanoma (malignant)

This rare form of rectal cancer typically causes recurrent rectal bleeding that arises from a painless, asymptomatic mass.

Small-intestine cancer

This disorder occasionally produces slight hematochezia or blood-streaked stools. Its characteristic features include colicky pain and postprandial vomiting. Other common signs and symptoms include anorexia, weight loss, and fever. Palpation may reveal abdominal masses.

Typhoid fever

About 10% of patients with typhoid fever develop hematochezia, which is occasionally massive. However, melena is more common. Both signs of bleeding occur late and may be accompanied by marked abdominal distention, diarrhea, significant weight loss, mental dullness, and profound fatigue. Earlier signs and symptoms are pathognomonic rose spots, headache, chills, fever, constipation, dry cough, conjunctivitis, and epistaxis.

Ulcerative proctitis

In this disorder, the patient typically has an intense urge to defecate but passes only bright red blood, pus, or mucus. Other common findings include acute constipation and tenesmus.

Other causes

Heavy metal poisoning

Bloody diarrhea is accompanied by cramping abdominal pain, nausea, and vomiting. Other signs may include tachycardia, hypotension, seizures, paresthesia, depressed or absent deep tendon reflexes, and an altered level of consciousness.

Tests

Certain procedures, especially colonoscopy, polypectomy, and proctosigmoidoscopy, may cause rectal bleeding. Bowel perforation is rare.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Vaginal bleeding, postmenopausal: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Atrophic vaginitis

When bloody staining occurs in this disorder, it usually follows coitus or douching. The characteristic watery white vaginal discharge may be accompanied by pruritus, dyspareunia, and a burning sensation in the vagina and labia. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Cervical cancer

Early invasive cervical cancer causes vaginal spotting or heavier bleeding, usually after coitus or douching but occasionally spontaneously. Related findings include a persistent, pink-tinged, and foul-smelling vaginal discharge and postcoital pain. As the cancer spreads, back and sciatic pain, leg swelling, anorexia, weight loss, hematuria, dysuria, rectal bleeding, and weakness may occur.

Cervical or endometrial polyps

These small, pedunculated growths may cause spotting (possibly as a mucopurulent pink discharge) after coitus, douching, or straining at defecation. However, many endometrial polyps produce no symptoms.

Endometrial hyperplasia or cancer

Bleeding occurs early in these disorders; it can be brownish and scant or bright red and profuse, and usually follows coitus or douching. Bleeding later becomes heavier and more frequent, leading to clotting and anemia. It may be accompanied by pelvic, rectal, low back, and leg pain and an enlarged uterus.

Ovarian tumors (feminizing)

Estrogen-producing ovarian tumors can stimulate endometrial shedding and cause heavy bleeding that isn’t associated with coitus or douching. A palpable pelvic mass, increased cervical mucus, breast enlargement, and spider angiomas may be present.

Vaginal cancer

Characteristic spotting or bleeding may be preceded by a thin, watery vaginal discharge. Bleeding may be spontaneous but usually follows coitus or douching. A firm, ulcerated vaginal lesion may be present; dyspareunia, urinary frequency, bladder and pelvic pain, rectal bleeding, and vulvar lesions may develop later.

Other causes

Drugs

Unopposed estrogen replacement therapy is a common cause of abnormal vaginal bleeding. This can usually be reduced by adding progesterone (in women who haven’t had a hysterectomy) and by adjusting the patient’s estrogen dosage.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Rectal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Hemorrhoid

❑ Rectal fissure

❑ Prostatitis

❑ Anal fistula

❑ Pruritus ani

❑ Fecal impaction

❑ Coccydynia

❑ Perirectal abscess

❑ Infected pilonidal cyst

❑ Ulcerative proctitis

❑ Infective proctitis

❑ Proctalgia fugax

❑ Anal carcinoma

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Gastrointestinal Bleeding: Differential Overview
(Field Guide to Bedside Diagnosis)

Upper GI

❑ Peptic ulcer disease

❑ Gastritis

❑ Mallory-Weiss tear

❑ Esophageal varices

❑ Esophagitis

❑ Epistaxis

❑ Esophageal cancer

❑ Gastric cancer

Lower GI

❑ Infectious diarrhea

❑ Diverticular bleeding

❑ Hemorrhoids

❑ Anal fissure

❑ Inflammatory bowel disease

❑ Angiodysplasia

❑ Colon cancer

❑ Mesenteric ischemia

❑ Aortoenteric fistula

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Hemorrhoids: Causes
(Handbook of Diseases)

Hemorrhoids result from activities that increase intravenous pressure, resulting in distention and engorgement. Predisposing factors include prolonged sitting, straining at defecation, constipation, low-fiber diet, pregnancy, and obesity.

Other factors include hepatic disease, such as cirrhosis, amebic abscesses, or hepatitis; alcoholism; and anorectal infections.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Hematochezia: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Amyloidosis

Hematochezia occasionally occurs when amyloidosis affects the GI tract. Massive, rapid hematochezia may precipitate signs of shock, such as hypotension and tachycardia. Associated signs and symptoms include hypoactive or absent bowel sounds, abdominal pain, malabsorption, diarrhea, and renal disease. The patient may also have a stiff, enlarged tongue, resulting in dysarthria.

Anal fissure

Slight hematochezia characterizes anal fissure; blood may streak the stools or appear on toilet tissue. Accompanying hematochezia is severe rectal pain that may make the patient reluctant to defecate, thereby causing constipation.

Angiodysplastic lesions

Most common in elderly patients, angiodysplastic lesions of the ascending colon typically cause chronic, bright red rectal bleeding. Occasionally, this painless hematochezia may result in life-threatening blood loss and signs of shock, such as tachycardia and hypotension.

Anorectal fistula

Blood, pus, mucus, and occasionally stools may drain from anorectal fistula. Other effects include rectal pain and pruritus.

Coagulation disorders

Patients with a coagulation disorder (such as thrombocytopenia and disseminated intravascular coagulation) may experience GI bleeding marked by moderate to severe hematochezia. Bleeding may also occur in other body systems, producing such signs as epistaxis and purpura. Associated findings vary with the specific coagulation disorder.

Colitis

Ischemic colitis commonly causes bloody diarrhea, especially in elderly patients. The hematochezia may be slight or massive and is usually accompanied by severe, cramping lower abdominal pain and hypotension. Other effects include abdominal tenderness, distention, and absent bowel sounds. Severe colitis may cause life-threatening hypovolemic shock and peritonitis.

Ulcerative colitis typically causes bloody diarrhea that may also contain mucus. The hematochezia is preceded by mild to severe abdominal cramps and may cause slight to massive blood loss. Associated signs and symptoms include fever, tenesmus, anorexia, nausea, vomiting, hyperactive bowel sounds and, occasionally, tachycardia. Weight loss and weakness occur late.

Colon cancer

Bright red rectal bleeding with or without pain is a telling sign, especially in cancer of the left colon.

Usually, a left colon tumor causes early signs of obstruction, such as rectal pressure, bleeding, and intermittent fullness or cramping. As the disease progresses, the patient also develops obstipation, diarrhea, or ribbon-shaped stools, and pain, which is typically relieved by passage of stools or flatus. Stools are grossly bloody.

Early tumor growth in the right colon may cause melena, abdominal aching, pressure, and dull cramps. As the disease progresses, the patient develops weakness and fatigue. Later, he may also experience diarrhea, anorexia, weight loss, anemia, vomiting, abdominal mass, and signs of obstruction, such as abdominal distention and abnormal bowel sounds.

Colorectal polyps

Colorectal polyps are the most common cause of intermittent hematochezia in adults younger than age 60; however, sometimes such polyps produce no symptoms. When located high in the colon, polyps may cause blood-streaked stools. The stools yield a positive response when tested with guaiac. If the polyps are located closer to the rectum, they may bleed freely.

Crohn’s disease

Hematochezia isn’t a common sign of Crohn’s disease unless the perineum is involved. If rectal bleeding occurs, it’s likely to be massive. The chief clinical features of Crohn’s disease include fever, abdominal distention and pain with guarding, diarrhea, hyperactive bowel sounds, anorexia, nausea, and fatigue. A palpable mass in the colon area may be present.

Diverticulitis

Most common in elderly patients, diverticulitis can suddenly cause mild to moderate rectal bleeding after the patient feels the urge to defecate. The bleeding may end abruptly or may progress to life-threatening blood loss with signs of shock. Associated signs and symptoms may include left-lower-quadrant pain that’s relieved by defecation, alternating episodes of constipation and diarrhea, anorexia, nausea and vomiting, rebound tenderness, and a distended tympanic abdomen.

Dysentery

Bloody diarrhea is common in infection with Shigella, Amoeba, and Campylobacter, but rare with Salmonella. Abdominal pain or cramps, tenesmus, fever, and nausea may also occur.

Esophageal varices (ruptured)

Ruptured esophageal varices is a life-threatening disorder, in which hematochezia may range from slight rectal oozing to grossly bloody stools and may be accompanied by mild to severe hematemesis or melena. This painless but massive hemorrhage may precipitate signs of shock, such as tachycardia and hypotension. In fact, signs of shock occasionally precede overt signs of bleeding. Typically, the patient has a history of chronic liver disease.

Food poisoning (staphylococcal)

The patient may have bloody diarrhea 1 to 6 hours after ingesting food toxins. Accompanying signs and symptoms include severe, cramping abdominal pain, nausea and vomiting, and prostration, all of which last a few hours.

Hemorrhoids

Hematochezia may accompany external hemorrhoids, which typically cause painful defecation, resulting in constipation. Less painful internal hemorrhoids usually produce more chronic bleeding with bowel movements, which may eventually lead to signs of anemia, such as weakness and fatigue.

Leptospirosis

The severe form of leptospirosis — Weil’s syndrome — produces hematochezia or melena along with other signs of bleeding, such as epistaxis and hemoptysis. The bleeding is typically preceded by a sudden frontal headache and severe thigh and lumbar myalgia that may be accompanied by cutaneous hyperesthesia. Conjunctival suffusion is indicative. Bleeding is followed by chills, a rapidly rising fever, and perhaps nausea and vomiting. Fever, headache, and myalgia usually intensify and persist for weeks. Other findings may include right-upper-quadrant tenderness, hepatomegaly, and jaundice.

Peptic ulcer

Upper GI bleeding is a common complication in peptic ulcer. The patient may display hematochezia, hematemesis, or melena, depending on the rapidity and amount of bleeding. If the peptic ulcer penetrates an artery or vein, massive bleeding may precipitate signs of shock, such as hypotension and tachycardia. Other findings may include chills, fever, nausea and vomiting, and signs of dehydration, such as dry mucous membranes, poor skin turgor, and thirst. The patient typically has a history of epigastric pain that’s relieved by foods or antacids; he may also have a history of habitual use of tobacco, alcohol, or NSAIDs.

Rectal melanoma (malignant)

Rectal melanoma is a rare form of rectal cancer that typically causes recurrent rectal bleeding that arises from a painless, asymptomatic mass.

Small-intestine cancer

Small-intestine cancer occasionally produces slight hematochezia or blood-streaked stools. Its characteristic features include colicky pain and postprandial vomiting. Other common signs and symptoms include weight loss, anorexia, and fever. Palpation may reveal abdominal masses.

Typhoid fever

About 10% of patients with typhoid fever develop hematochezia, which is occasionally massive. However, melena is more common. Both signs of bleeding occur late and may be accompanied by mental dullness, marked abdominal distention, diarrhea, significant weight loss, and profound fatigue. Among earlier signs and symptoms are pathognomonic rose spots, headache, chills, fever, constipation, dry cough, conjunctivitis, and epistaxis.

Ulcerative proctitis

Ulcerative proctitis typically causes an intense urge to defecate, but the patient passes only bright red blood, pus, or mucus. Other common signs and symptoms include acute constipation and tenesmus.

Other causes

Diagnostic tests

Certain procedures, especially colonoscopy, polypectomy, and proctosigmoidoscopy, may cause rectal bleeding. Bowel perforation is rare.

Heavy metal poisoning

Bloody diarrhea is accompanied by cramping abdominal pain, nausea, and vomiting. Other signs may include tachycardia, hypotension, seizures, paresthesia, depressed or absent deep tendon reflexes, and an altered level of consciousness.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Melena: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Colon cancer

On the right side of the colon, early tumor growth may cause melena accompanied by abdominal aching, pressure, or cramps. As the disease progresses, the patient develops weakness, fatigue, and anemia. Eventually, he also experiences diarrhea or obstipation, anorexia, weight loss, vomiting, and other signs and symptoms of intestinal obstruction.

With a tumor on the left side, melena is a rare sign until late in the disease. Early tumor growth commonly causes rectal bleeding with intermittent abdominal fullness or cramping and rectal pressure. As the disease progresses, the patient may develop obstipation, diarrhea, or pencil-shaped stools. At this stage, bleeding from the colon is signaled by melena or bloody stools.

Ebola virus

Melena, hematemesis, and bleeding from the nose, gums, and vagina may occur later with Ebola virus. Patients usually report abrupt onset of headache, malaise, myalgia, high fever, diarrhea, abdominal pain, dehydration, and lethargy on the fifth day of illness. Pleuritic chest pain, dry hacking cough, and pharyngitis have also been noted. A maculopapular rash develops between days 5 and 7 of the illness.

Esophageal cancer

Melena is a late sign of esophageal cancer that’s three times more common in males than females. Increasing obstruction first produces painless dysphagia, then rapid weight loss. The patient may experience steady chest pain with substernal fullness, nausea, vomiting, and hematemesis. Other findings include hoarseness, persistent cough (possibly hemoptysis), hiccups, sore throat, and halitosis. In the later stages, signs and symptoms include painful dysphagia, anorexia, and regurgitation.

Esophageal varices (ruptured)

Esophageal varices is a life-threatening disorder that can produce melena, hematochezia, and hematemesis. Melena is preceded by signs of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. Agitation or confusion signals developing hepatic encephalopathy.

Gastric cancer

Melena and altered bowel habits may occur late with gastric cancer. More common findings include insidious onset of upper abdominal or retrosternal discomfort and chronic dyspepsia, which are unrelieved by antacids and exacerbated by food. Anorexia and slight nausea often occur, along with hematemesis, pallor, fatigue, weight loss, and a feeling of abdominal fullness.

Gastritis

Melena and hematemesis are common. The patient may also experience mild epigastric or abdominal discomfort that’s exacerbated by eating; belching; nausea; vomiting; and malaise.

Malaria

Melena may accompany persistent high fever and orthostatic hypotension in severe malaria. Other features include hemoptysis, vomiting, abdominal pain, diarrhea, oliguria, and headache, seizures, delirium, or coma. These findings are interspersed throughout the malarial paroxysm — chills, then high fever, and then profuse diaphoresis.

Mallory-Weiss syndrome

Mallory-Weiss syndrome is characterized by massive bleeding from the upper GI tract due to a tear in the mucous membrane of the esophagus or the junction of the esophagus and the stomach. Melena and hematemesis follow vomiting. Severe upper abdominal bleeding leads to signs and symptoms of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. The patient may also report epigastric or back pain.

Mesenteric vascular occlusion

Mesenteric vascular occlusion is a life-threatening disorder that produces slight melena with 2 to 3 days of persistent, mild abdominal pain. Later, abdominal pain becomes severe and may be accompanied by tenderness, distention, guarding, and rigidity. The patient may also experience anorexia, vomiting, fever, and profound shock.

Peptic ulcer

Melena may signal life-threatening hemorrhage from vascular penetration. The patient may also develop decreased appetite, nausea, vomiting, hematemesis, hematochezia, and left epigastric pain that’s gnawing, burning, or sharp and may be described as heartburn or indigestion. With hypovolemic shock comes tachycardia, tachypnea, hypotension, dizziness, syncope, and cool, clammy skin.

Small-bowel tumors

Small-bowel tumors may bleed and produce melena. Other signs and symptoms include abdominal pain, distention, and increasing frequency and pitch of bowel sounds.

Thrombocytopenia

Melena or hematochezia may accompany other manifestations of bleeding tendency: hematemesis, epistaxis, petechiae, ecchymoses, hematuria, vaginal bleeding, and characteristic blood-filled oral bullae. Typically, the patient displays malaise, fatigue, weakness, and lethargy.

Typhoid fever

Melena or hematochezia occurs late in typhoid fever and may occur with hypotension and hypothermia. Other late findings include mental dullness or delirium, marked abdominal distention and diarrhea, marked weight loss, and profound fatigue.

Yellow fever

Melena, hematochezia, and hematemesis are ominous signs of hemorrhage, a classic feature, which occurs along with jaundice. Other findings include fever, headache, nausea, vomiting, epistaxis, albuminuria, petechiae and mucosal hemorrhage, and dizziness.

Other causes

Drugs and alcohol

Aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), or alcohol can cause melena as a result of gastric irritation.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Hematochezia: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Anal fissure

Slight hematochezia characterizes an anal fissure; blood may streak the stools or appear on toilet tissue. Accompanying hematochezia is severe rectal pain that may make the patient reluctant to defecate, thereby causing constipation.

Anorectal fistula

Blood, pus, mucus, and occasionally stools may drain from an anorectal fistula. Other effects include rectal pain and pruritus. If an abscess is present, the patient may have a fever.

Coagulation disorders

Patients with a coagulation disorder (such as thrombocytopenia and disseminated intravascular coagulation) may experience GI bleeding marked by moderate to severe hematochezia. Bleeding may also occur in other body systems, producing such signs as epistaxis and purpura. Associated findings vary with the specific coagulation disorder.

Colitis

Ischemic colitis commonly causes hematochezia, especially in elderly patients. The hematochezia may be slight or massive and is usually accompanied by severe, cramping lower abdominal pain and hypotension. Other effects include abdominal tenderness, distention, and absent bowel sounds. Severe colitis may cause life-threatening hypovolemic shock and peritonitis.

Ulcerative colitis typically causes hematochezia that may also contain mucus. The hematochezia is preceded by mild to severe abdominal cramps and may cause slight to massive blood loss. Associated signs and symptoms include fever, tenesmus, anorexia, nausea, vomiting, hyperactive bowel sounds and, occasionally, tachycardia. Weight loss and weakness occur late.

Colon cancer

Bright red rectal bleeding with or without pain is a telling sign, especially in cancer of the left colon. Usually, a left colon tumor causes early signs of obstruction, such as rectal pressure, bleeding, and intermittent fullness or cramping. As the disease progresses, the patient also develops obstipation, diarrhea, or ribbon-shaped stools, and pain, which is typically relieved by passage of stools or flatus. Stools are grossly bloody.

Early tumor growth in the right colon may cause melena, abdominal aching, pressure, and dull cramps. As the disease progresses, the patient develops weakness and fatigue. Later, he may also experience diarrhea, anorexia, weight loss, anemia, vomiting, abdominal mass, and signs of obstruction, such as abdominal distention and abnormal bowel sounds.

Colorectal polyps

Colorectal polyps are the most common cause of intermittent hematochezia in adults younger than age 60; however, sometimes such polyps produce no symptoms. When located high in the colon, polyps may cause blood-streaked stools. The stools yield a positive response when tested with guaiac. If the polyps are located closer to the rectum, they may bleed freely.

Crohn’s disease

Hematochezia isn’t a common sign of Crohn’s disease unless the perineum is involved. If rectal bleeding occurs, it’s likely to be massive. The chief clinical features of Crohn’s disease include fever, abdominal distention and pain with guarding, diarrhea, hyperactive bowel sounds, anorexia, nausea, and fatigue. A palpable mass in the colon area may be present.

Diverticulitis

Most common in elderly patients, diverticulitis can suddenly cause mild to moderate rectal bleeding after the patient feels the urge to defecate. The bleeding may end abruptly or may progress to life-threatening blood loss with signs of shock. Associated signs and symptoms may include left-lower-quadrant pain that’s relieved by defecation, alternating episodes of constipation and diarrhea, anorexia, nausea and vomiting, rebound tenderness, and a distended tympanic abdomen.

Dysentery

Bloody diarrhea is common in infection with Shigella, Amoeba, and Campylobacter, but rare with Salmonella. In addition, abdominal pain or cramps, tenesmus, fever, and nausea may occur. Signs and symptoms of dehydration may also be present.

Esophageal varices (ruptured)

When an esophageal varix ruptures (a life-threatening condition), hematochezia may range from slight rectal oozing to grossly bloody stools and may be accompanied by mild to severe hematemesis or melena. This painless but massive hemorrhage may precipitate signs of shock, such as tachycardia and hypotension. In fact, signs of shock occasionally precede overt signs of bleeding. Typically, the patient with esophageal varices has a history of chronic liver disease.

Food poisoning (staphylococcal)

The patient with staphylococcal food poisoning may have bloody diarrhea 1 to 6 hours after ingesting food toxins. Accompanying signs and symptoms include severe, cramping abdominal pain, nausea and vomiting, and prostration, all of which last a few hours.

Hemorrhoids

Hematochezia may accompany external hemorrhoids, which typically cause painful defecation, resulting in constipation. Less painful internal hemorrhoids usually produce more chronic bleeding with bowel movements, which may eventually lead to signs of anemia, such as weakness and fatigue.

Peptic ulcer

Upper GI bleeding is a common complication in peptic ulcer. The patient may display hematochezia, hematemesis, or melena, depending on the rapidity and amount of bleeding. If the peptic ulcer penetrates an artery or vein, massive bleeding may precipitate signs of shock, such as hypotension and tachycardia. Other findings may include chills, fever, nausea and vomiting, and signs of dehydration, such as dry mucous membranes, poor skin turgor, and thirst. The patient typically has a history of epigastric pain that’s relieved by foods or antacids; he may also have a history of habitual use of tobacco, alcohol, or nonsteroidal anti-inflammatory drugs.

Small-intestine cancer

Small-intestine cancer occasionally produces slight hematochezia or blood-streaked stools. Its characteristic features include colicky pain and postprandial vomiting. Other common signs and symptoms include weight loss, anorexia, and fever. Palpation may reveal abdominal masses.

Ulcerative proctitis

Ulcerative proctitis typically causes an intense urge to defecate, but the patient passes only bright red blood, pus, or mucus. Other common signs and symptoms include acute constipation and tenesmus.

Other causes

Diagnostic tests

Certain procedures, especially colonoscopy, polypectomy, and proctosigmoidoscopy, may cause rectal bleeding. Bowel perforation is rare.

Heavy metal poisoning

Bloody diarrhea is accompanied by cramping abdominal pain, nausea, and vomiting. Other signs may include tachycardia, hypotension, seizures, paresthesia, depressed or absent deep tendon reflexes, and an altered level of consciousness.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Melena: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Colon cancer

On the right side of the colon, early tumor growth may cause melena accompanied by abdominal aching, pressure, or cramps. As the disease progresses, the patient develops weakness, fatigue, and anemia. Eventually, he also experiences diarrhea or obstipation, anorexia, weight loss, vomiting, and other signs and symptoms of intestinal obstruction.

With a tumor on the left side, melena is a rare sign until late in the disease. Early tumor growth commonly causes rectal bleeding with intermittent abdominal fullness or cramping and rectal pressure. As the disease progresses, the patient may develop obstipation, diarrhea, or pencil-shaped stools. At this stage, bleeding from the colon is signaled by melena or bloody stools.

CULTURAL CUE:Ask your patient about his religious and ethnic background to determine if they put him at risk for colon cancer. Colon cancer is more prevalent in Jewish people of Eastern European descent.

Esophageal cancer

Melena is a late sign of esophageal cancer, a malignant neoplastic disease. Increasing obstruction first produces painless dysphagia, then rapid weight loss. The patient may experience steady chest pain with substernal fullness, nausea, vomiting, and hematemesis. Other findings include hoarseness, persistent cough (possibly hemoptysis), hiccups, sore throat, and halitosis. In the later stages, signs and symptoms include painful dysphagia, anorexia, and regurgitation.

Esophageal varices (ruptured)

This life-threatening disorder can produce melena, hematochezia, and hematemesis. Melena is preceded by signs of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. Agitation or confusion signals developing hepatic encephalopathy.

Gastric cancer

Melena and altered bowel habits may occur late with gastric cancer. More common findings include insidious onset of upper abdominal or retrosternal discomfort and chronic dyspepsia that are unrelieved by antacids and are exacerbated by food. Anorexia and slight nausea usually occur, along with hematemesis, pallor, fatigue, weight loss, and a feeling of abdominal fullness.

CULTURAL CUE:Asian countries, such as Korea, China, Taiwan, and Japan, have higher rates of gastric cancer than the United States.


Gastritis

Melena and hematemesis are common in gastritis. The patient may also experience mild epigastric or abdominal discomfort that’s exacerbated by eating, belching, nausea, vomiting, and malaise.

Mallory-Weiss syndrome

Mallory-Weiss syndrome is characterized by massive bleeding from the upper GI tract due to a tear in the mucous membrane of the esophagus or the junction of the esophagus and the stomach. Melena and hematemesis follow vomiting. Severe upper abdominal bleeding leads to signs and symptoms of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. The patient may also report epigastric or back pain.

Mesenteric vascular occlusion

Mesenteric vascular occlusion is a life-threatening disorder that produces slight melena with 2 to 3 days of persistent, mild abdominal pain. Later, abdominal pain becomes severe and may be accompanied by tenderness, distention, guarding, and rigidity. The patient may also experience anorexia, vomiting, fever, and profound shock.

Peptic ulcer

Melena may signal life-threatening hemorrhage from vascular penetration in patients with peptic ulcers. The patient may also develop decreased appetite, nausea, vomiting, hematemesis, hematochezia, and left epigastric pain that’s gnawing, burning, or sharp and may be described as heartburn or indigestion. With hypo-volemic shock come tachycardia, tachypnea, hypotension, dizziness, syncope, and cool, clammy skin.

Small-bowel tumors

Small-bowel tumors may bleed and produce melena. Other signs and symptoms include abdominal pain, distention, and increasing frequency and pitch of bowel sounds.

Thrombocytopenia

With thrombocytopenia, melena or hematochezia may accompany other manifestations of bleeding tendency: hematemesis, epistaxis, petechiae, ecchymoses, hematuria, vaginal bleeding, and characteristic blood-filled oral bullae. Typically, the patient displays malaise, fatigue, weakness, and lethargy.

Other causes

Drugs and alcohol

Aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), or alcohol can cause melena as a result of gastric irritation.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Rectal pain: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abscess

A perirectal abscess can occur in various locations in the rectum and anus, causing pain in the perianal area. Typically, a superficial abscess produces constant, throbbing, local pain that’s exacerbated by sitting or walking. The local pain associated with a deeper abscess may begin insidiously high in the rectum or even in the lower abdomen and is accompanied by an indurated anal mass. The patient may also develop such associated signs and symptoms as fever, malaise, anal swelling and inflammation, purulent drainage, and local tenderness.

A prostatic abscess occasionally produces rectal pain. Common associated findings include urine retention and frequency, dysuria, and fever. A rectal examination may reveal prostatic tenderness and gas.

Anal fissure

An anal fissure is a longitudinal crack in the anal lining that causes sharp rectal pain on defecation. The patient typically experiences a burning sensation and gnawing pain that can continue up to 4 hours after defecation. Fear of provoking this pain may lead to acute constipation. The patient may also develop anal pruritus and extreme tenderness and may report finding spots of blood on the toilet tissue after defecation.

Anorectal fistula

Pain develops when a tract formed between the anal canal and skin temporarily seals. It persists until drainage resumes. Other chief complaints of an anorectal fistula include pruritus and drainage of pus, blood, mucus and, occasionally, stool.

Cryptitis

Cryptitis results when particles of stool that are lodged in the anal folds decay and cause infection, which may produce dull anal pain or discomfort and anal pruritus. Intense pain may occur when the anal sphincter contracts.

Hemorrhoids

Thrombosed or prolapsed hemorrhoids cause rectal pain that may worsen during defecation and abate after it. The patient’s fear of provoking the pain may lead to constipation. Usually, rectal pain is accompanied by severe itching. Internal hemorrhoids may also produce mild, intermittent bleeding that characteristically occurs as spotting on the toilet tissue or on the stool surface. External hemorrhoids are visible outside the anal sphincter.

Proctalgia fugax

With proctalgia fugax, muscle spasms of the rectum and pelvic floor produce sudden, severe episodes of rectal pain that last up to several minutes and then disappear. The patient may report being awakened by the pain, which is sometimes associated with stress or anxiety and relieved by food and drink.

Other causes

Anal intercourse

Shearing forces may cause inflammation or tearing of the mucous membranes and discomfort.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Vaginal bleeding, postmenopausal: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Atrophic vaginitis

When bloody staining occurs in atrophic vaginitis, it usually follows coitus or douching. Characteristic white, watery vaginal discharge may be accompanied by pruritus, dyspareunia, and a burning sensation in the vagina and labia. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Cervical cancer

Early invasive cervical cancer causes vaginal spotting or heavier bleeding, usually after coitus or douching but occasionally spontaneously. Related findings include persistent, pink-tinged, and foul-smelling vaginal discharge and postcoital pain. As the cancer spreads, back and sciatic pain, leg swelling, anorexia, weight loss, hematuria, dysuria, rectal bleeding, and weakness may occur.

Cervical or endometrial polyps

Cervical or endometrial polyps are small, pedunculated growths that may cause spotting (possibly as a mucopurulent, pink discharge) after coitus, douching, or straining at stool. Many endometrial polyps produce no symptoms, however.

Endometrial hyperplasia or cancer

With endometrial hyperplasia or cancer, bleeding occurs early, can be brownish and scant or bright red and profuse, and usually follows coitus or douching. Bleeding later becomes heavier and more frequent, leading to clotting and anemia. Bleeding may be accompanied by pelvic, rectal, lower back, and leg pain. The uterus may be enlarged.

Ovarian tumor (feminizing)

Estrogen-producing ovarian tumors can stimulate endometrial shedding and cause heavy bleeding unassociated with coitus or douching. A palpable pelvic mass, increased cervical mucus, breast enlargement, and spider angiomas may be present.

Vaginal cancer

With vaginal cancer, characteristic spotting or bleeding may be preceded by a thin, watery vaginal discharge. Bleeding may be spontaneous but usually follows coitus or douching. A firm, ulcerated vaginal lesion may be present; dyspareunia, urinary frequency, bladder and pelvic pain, rectal bleeding, and vulvar lesions may develop later.

Other causes

Drugs

Unopposed estrogen replacement therapy is a common cause of abnormal vaginal bleeding. This can usually be reduced by adding progesterone (in women who haven’t had a hysterectomy) and by adjusting the patient’s estrogen dosage.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Gastrointestinal Bleeding: Principal Causes of Gastrointestinal Bleeding
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  1. Uppergastrointestinal bleeding
    1. Nose
    2. Mouth and pharynx
    3. Esophagus
      1. Esophagitis
        1. Gastroesophageal reflux
        2. Caustic ingestion
        3. Infection
      2. Foreign body
      3. Varices
      4. Duplication
    4. Gastroesophageal junction
      1. Mallory-Weisstear
    5. Stomach
      1. Gastritis
      2. Ulcer
      3. Duplication
      4. Vascular malformation
      5. Neoplasm
    6. Duodenum
      1. Ulcer
      2. Foreign body
      3. Varices
      4. Duplication
      5. Vascular malformation
      6. Hemobilia
    7. Other
      1. Swallowed blood
      2. Coagulopathy
        1. Hemorrhagic disease of the newborn(vitamin K deficiency)
        2. Disseminated intravascular coagulation
      3. Drugs
  2. Lower gastrointestinal bleeding
    1. Intestine
      1. Cow milk/soyprotein sensitivity
      2. Necrotizing enterocolitis
      3. Infectious colitis
      4. Henoch-Schönlein purpura
      5. Intussusception
      6. Congenital aganglionic megacolon (Hirschsprungdisease)
      7. Meckel diverticulum
      8. Volvulus with malrotation
      9. Inflammatory bowel disease
      10. Intestinal polyps
        1. Solitaryjuvenile polyps/juvenile intestinal polyposis
        2. Adenomatous polyposis of the colon
        3. Peutz-Jeghers syndrome
        4. Benign lymphoid hyperplasia
        5. Duplication
        6. Vascular malformation
        7. Neoplasm
    2. Rectum and anus
      1. Anal fissure
      2. Trauma
      3. Sexual abuse
      4. Hemorrhoids
      5. Other
    3. Swallowed blood
    4. Coagulopathy
    5. Drugs
  3. Factitious bleeding

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Melena: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Colon cancer.On the right side of the colon, early tumor growth may cause melena accompanied by abdominal aching, pressure, or cramps. As the disease progresses, the patient develops weakness, fatigue, and anemia. Eventually, he also experiences diarrhea or obstipation, anorexia, weight loss, vomiting, and other signs and symptoms of intestinal obstruction.

With a tumor on the left side of the colon, melena is a rare sign until late in the disease. Early tumor growth commonly causes rectal bleeding with intermittent abdominal fullness or cramping and rectal pressure. As the disease progresses, the patient may develop obstipation, diarrhea, or pencil-shaped stools. At this stage, bleeding from the colon is signaled by melena or bloody stools.

Ebola virus.Melena, hematemesis, and bleeding from the nose, gums, and vagina may occur later with Ebola virus. Patients usually report an abrupt onset of headache, malaise, myalgia, high fever, diarrhea, abdominal pain, dehydration, and lethargy on the fifth day of illness. Pleuritic chest pain, a dry hacking cough, and pharyngitis have also been noted. A maculopapular rash develops between days 5 and 7 of the illness.

Esophageal cancer.Melena is a late sign of esophageal cancer. Increasing obstruction first produces painless dysphagia, then rapid weight loss. The patient may experience steady chest pain with substernal fullness, nausea, vomiting, and hematemesis. Other findings include hoarseness, a persistent cough (possibly hemoptysis), hiccups, a sore throat, and halitosis. In the later stages, signs and symptoms include painful dysphagia, anorexia, and regurgitation.

Esophageal varices (ruptured).Ruptured esophageal varices is a life-threatening disorder that can produce melena, hematochezia, and hematemesis. Melena is preceded by signs of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. Agitation or confusion signals developing hepatic encephalopathy.

Gastritis.Melena and hematemesis are common with gastritis. The patient may also experience mild epigastric or abdominal discomfort that's exacerbated by eating, belching, nausea, vomiting, and malaise.

Mallory-Weiss syndrome.

Mallory-Weiss syndrome is characterized by massive bleeding from the upper GI tract due to a tear in the mucous membrane of the esophagus or the junction of the esophagus and the stomach. Melena and hematemesis follow vomiting. Severe upper abdominal bleeding leads to signs and symptoms of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. The patient may also report epigastric or back pain.

Mesenteric vascular occlusion.Mesenteric vascular occlusion is a life-threatening disorder that produces slight melena with 2 or 3 days of persistent, mild abdominal pain. Later, abdominal pain becomes severe and may be accompanied by tenderness, distention, guarding, and rigidity. The patient may also experience anorexia, vomiting, fever, and profound shock.

Peptic ulcer.With a peptic ulcer, melena may signal life-threatening hemorrhage from vascular penetration. The patient may also develop decreased appetite, nausea, vomiting, hematemesis, hematochezia, and left epigastric pain that's gnawing, burning, or sharp and may be described as heartburn or indigestion. With hypovolemic shock come tachycardia, tachypnea, hypotension, dizziness, syncope, and cool, clammy skin.

Small-bowel tumors.Small-bowel tumors may bleed and produce melena. Other signs and symptoms include abdominal pain, distention, and an increasing frequency and pitch of bowel sounds.

Thrombocytopenia.Melena or hematochezia may accompany other manifestations of bleeding tendency that occurs with thrombocytoenia: hematemesis, epistaxis, petechiae, ecchymoses, hematuria, vaginal bleeding, and characteristic blood-filled oral bullae. Typically, the patient displays malaise, fatigue, weakness, and lethargy.

Typhoid fever.Melena or hematochezia occurs late in typhoid fever and may occur with hypotension and hypothermia. Other late findings include mental dullness or delirium, marked abdominal distention and diarrhea, marked weight loss, and profound fatigue.

Yellow fever.Melena, hematochezia, and hematemesis are ominous signs of hemorrhage, a classic feature of yellow fever, which occurs along with jaundice. Other findings include fever, headache, nausea, vomiting, epistaxis, albuminuria, petechiae and mucosal hemorrhage, and dizziness.

Other causes

Drugs and alcohol.Aspirin, other nonsteroidal anti-inflammatory drugs, or alcohol can cause melena as a result of gastric irritation.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Rectal pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abscess (perirectal).A perirectal abscess can occur in various locations in the rectum and anus, causing pain in the perianal area. Typically, a superficial abscess produces constant, throbbing local pain that's exacerbated by sitting or walking. The local pain associated with a deeper abscess may begin insidiously, commonly high in the rectum or even in the lower abdomen, and is accompanied by an indurated anal mass. The patient may also develop associated signs and symptoms, such as fever, malaise, anal swelling and inflammation, purulent drainage, and local tenderness.

Anal fissure.An anal fissure causes sharp rectal pain on defecation. The patient typically experiences a burning sensation and gnawing pain that can continue up to 4 hours after defecation. Fear of provoking this pain may lead to acute constipation. The patient may also develop anal pruritus and extreme tenderness and may report finding spots of blood on the toilet tissue after defecation.

Anorectal fistula.Anorectal fistula causes rectal pain to develop when a tract formed between the anal canal and skin temporarily seals. It persists until drainage resumes. Other chief complaints include pruritus and drainage of pus, blood, mucus and, occasionally, stools.

Hemorrhoids.Thrombosed or prolapsed hemorrhoids cause rectal pain that may worsen during defecation and abate after it. The patient's fear of provoking the pain may lead to constipation. Usually, rectal pain is accompanied by severe itching. Internal hemorrhoids may also produce mild, intermittent bleeding that characteristically occurs as spotting on the toilet tissue or on the stool surface. External hemorrhoids are visible outside the anal sphincter.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Hematochezia [Rectal bleeding]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Anal fissure.Slight hematochezia characterizes anal fissure; blood may streak the stools or appear on toilet tissue. Accompanying hematochezia is severe rectal pain that may make the patient reluctant to defecate, thereby causing constipation.

Angiodysplastic lesions.Most common in elderly patients, these arteriovenous lesions of the ascending colon typically cause chronic, bright red rectal bleeding. Occasionally, this painless hematochezia may result in life-threatening blood loss and signs of shock, such as tachycardia and hypotension.

Coagulation disorders.Patients with a coagulation disorder (such as thrombocytopenia and disseminated intravascular coagulation) may experience GI bleeding marked by moderate to severe hematochezia. Bleeding may also occur in other body systems, producing such signs as epistaxis and purpura. Associated findings vary with the specific coagulation disorder.

Colitis.Ischemic colitis commonly causes bloody diarrhea, especially in elderly patients. Hematochezia may be slight or massive and is usually accompanied by severe, cramping lower abdominal pain and hypotension. Other effects include abdominal tenderness, distention, and absent bowel sounds. Severe colitis may cause life-threatening hypovolemic shock and peritonitis.

Ulcerative colitis typically causes bloody diarrhea that may also contain mucus. Hematochezia is preceded by mild to severe abdominal cramps and may cause slight to massive blood loss. Associated signs and symptoms include fever, tenesmus, anorexia, nausea, vomiting, hyperactive bowel sounds and, occasionally, tachycardia. Weight loss and weakness occur late.

Colon cancer.Bright red rectal bleeding with or without pain is a telling sign of colon cancer especially in cancer of the left colon.

Usually, a left colon tumor causes early signs of obstruction, such as rectal pressure, bleeding, and intermittent fullness or cramping. As the disease progresses, the patient also develops obstipation, diarrhea or ribbon-shaped stools, and pain, which is typically relieved by the passage of stools or flatus. Stools are grossly bloody.

Early tumor growth in the right colon may cause melena, abdominal aching, pressure, and dull cramps. As the disease progresses, the patient develops weakness and fatigue. Later, he may also experience diarrhea, anorexia, weight loss, anemia, vomiting, an abdominal mass, and signs of obstruction, such as abdominal distention and abnormal bowel sounds.

Colorectal polyps.Colorectal polyps are the most common cause of intermittent hematochezia in adults younger than age 60; however, sometimes such polyps produce no symptoms. When located high in the colon, polyps may cause blood-streaked stools. The stools yield a positive response when tested with guaiac. If the polyps are located closer to the rectum, they may bleed freely.

Diverticulitis.Most common in the elderly patient, diverticulitis can suddenly cause mild to moderate rectal bleeding after the patient feels the urge to defecate. The bleeding may end abruptly or may progress to life-threatening blood loss with signs of shock. Associated signs and symptoms may include left lower quadrant pain that's relieved by defecation, alternating episodes of constipation and diarrhea, anorexia, nausea and vomiting, rebound tenderness, and a distended tympanic abdomen.

Dysentery.Bloody diarrhea is common in infection with Shigella, Amoeba, and Campylobacter, but rare with Salmonella. Abdominal pain or cramps, tenesmus, a fever, and nausea may also occur.

Esophageal varices (ruptured).In esophageal varices, a life-threatening disorder, hematochezia may range from slight rectal oozing to grossly bloody stools and may be accompanied by mild to severe hematemesis or melena. This painless but massive hemorrhage may precipitate signs of shock, such as tachycardia and hypotension. In fact, signs of shock occasionally precede overt signs of bleeding. Typically, the patient has a history of chronic liver disease.

Food poisoning (staphylococcal).The patient may have bloody diarrhea 1 to 6 hours after ingesting food toxins. Accompanying signs and symptoms include severe, cramping abdominal pain; nausea and vomiting; and prostration, all of which last a few hours.

Hemorrhoids.Hematochezia may accompany external hemorrhoids, which typically cause painful defecation, resulting in constipation. Less painful internal hemorrhoids usually produce more chronic bleeding with bowel movements, which may eventually lead to signs of anemia, such as weakness and fatigue.

Leptospirosis.The severe form of leptospirosis—Weil's syndrome—produces hematochezia or melena along with other signs of bleeding, such as epistaxis and hemoptysis. The bleeding is typically preceded by a sudden frontal headache and severe thigh and lumbar myalgia that may be accompanied by cutaneous hyperesthesia. Conjunctival suffusion is indicative. Bleeding is followed by chills, a rapidly rising fever and, perhaps, nausea and vomiting. A fever, a headache, and myalgia usually intensify and persist for weeks. Other findings may include right upper quadrant tenderness, hepatomegaly, and jaundice.

Peptic ulcer.Upper GI bleeding is a common complication in peptic ulcer. The patient may display hematochezia, hematemesis, or melena, depending on the rapidity and amount of bleeding. If the peptic ulcer penetrates an artery or vein, massive bleeding may precipitate signs of shock, such as hypotension and tachycardia. Other findings may include chills, a fever, nausea and vomiting, and signs of dehydration, such as dry mucous membranes, poor skin turgor, and thirst. The patient typically has a history of epigastric pain that's relieved by foods or antacids; he may also have a history of habitually using tobacco, alcohol, or NSAIDs.

Ulcerative proctitis.Ulcerative proctitis typically causes an intense urge to defecate, but the patient passes only bright red blood, pus, or mucus. Other common signs and symptoms include acute constipation and tenesmus.

Other causes

Diagnostic tests.Certain procedures, especially colonoscopy, polypectomy, hemorrhoidectomy, and proctosigmoidoscopy, may cause rectal bleeding. Bowel perforation is rare.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Vaginal bleeding, postmenopausal: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Atrophic vaginitis.When bloody staining occurs with atrophic vaginitis, it usually follows coitus or douching. Characteristic white, watery vaginal discharge may be accompanied by pruritus, dyspareunia, and a burning sensation in the vagina and labia. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Cervical cancer.Early invasive cervical cancer causes vaginal spotting or heavier bleeding, usually after coitus or douching but occasionally spontaneously. Related findings include persistent, pink-tinged, and foul-smelling vaginal discharge and postcoital pain. As the cancer spreads, back and sciatic pain, leg swelling, anorexia, weight loss, hematuria, dysuria, rectal bleeding, and weakness may occur and the drainage may become dark and malodorous.

Cervical or endometrial polyps.Cervical or endometrial polyps are small, pedunculated growths that may cause spotting (possibly as a mucopurulent, pink discharge) after coitus, douching, or straining to defecate. Many endometrial polyps produce no symptoms.

Endometrial hyperplasia or cancer.Bleeding occurs early with endometrial hyperplasia or cancer; it can be brownish and scant or bright red and profuse, and usually follows coitus or douching. Bleeding later becomes heavier and more frequent, leading to clotting and anemia. Bleeding may be accompanied by pelvic, rectal, lower back, and leg pain. The uterus may be enlarged.

Ovarian tumors (feminizing).Ovarian tumors producing estrogen can stimulate endometrial shedding and cause heavy bleeding unassociated with coitus or douching. A palpable pelvic mass, increased cervical mucus, breast enlargement, and spider angiomas may be present.

Vaginal cancer.Characteristic spotting or bleeding with vaginal cancer may be preceded by a thin, watery vaginal discharge. Bleeding may be spontaneous but usually follows coitus or douching. A firm, ulcerated vaginal lesion may be present; dyspareunia, urinary frequency, bladder and pelvic pain, rectal bleeding, and vulvar lesions may develop later.

Other causes

Drugs.Unopposed estrogen replacement therapy is a common cause of abnormal vaginal bleeding. This can usually be reduced by adding progesterone (in women who haven't had a hysterectomy) and by adjusting the patient's estrogen dosage.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Lower GI Bleeding: Lower GI Bleeding - etiology
(The 5-Minute Pediatric Consult)

Reasons for lower GI bleeding at different ages:

  • Neonatal period (birth to 1 month):
    • Anorectal fissure
    • Necrotizing enterocolitis
    • Enteric infections
    • Allergic colitis
    • Upper GI source
    • Duplication cyst
    • Enterocolitis with Hirschsprung disease
    • Meckel diverticulum
    • Malrotation with volvulus
    • Hemorrhagic disease of the newborn
  • Infancy (1 month to 2 years):
    • Anorectal fissure
    • Enteric infections
    • Allergic colitis
    • Intussusception
    • Meckel diverticulum
    • Malrotation with volvulus
    • Lymphonodular hyperplasia
    • Upper GI source
    • Duplication cyst
    • Enterocolitis with Hirschsprung disease
    • Vascular malformation
  • Preschool age (2–5 years):
    • Anorectal fissure
    • Enteric infections
    • Polyps
    • Parasites
    • Meckel diverticulum
    • Intussusception
    • Lymphonodular hyperplasia
    • Inflammatory bowel disease
    • Enterocolitis with Hirschsprung disease
    • Hemolytic uremic syndrome
    • Henoch-Schönlein purpura
    • Vascular malformation
    • Child abuse
    • Perianal streptococcal cellulitis
  • School age (5–13 years):
    • Anorectal fissure
    • Enteric infections
    • Inflammatory bowel disease
    • Intussusception
    • Meckel diverticulum
    • Polyps
    • Henoch-Schönlein purpura
    • Hemolytic uremic syndrome
    • Parasites
    • Child abuse
    • Vascular malformations
    • Perianal streptococcal cellulitis
  • Adolescent (>13 years):
    • Anorectal fissure
    • Enteric infections
    • Inflammatory bowel disease
    • Hemolytic uremic syndrome
    • Intussusception
    • Midgut volvulus
    • Polyps
    • Vascular malformations
    • Lymphonodular hyperplasia
    • Parasites
    • Hemorrhoids

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008


 » Next page: Risk Factors for Gastrointestinal bleeding

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

Tools & Services:

Medical Articles:

Forums & Message Boards
 
HONcode We subscribe to the HONcode principles

By using this site you agree to our Terms of Use. Information provided on this site is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information on this site is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs. Please see our Terms of Use.

Home | Symptoms | Diseases | Diagnosis | Videos | Tools | Forum | About Us | Terms of Use | Privacy Policy | Site Map | Advertise

Copyright © 2009 Health Grades Inc. All rights reserved.