Gastrointestinal Bleeding

Differential Overview

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

DIagnostic Approach

With overt bleeding, determining whether a source is proximal or distal to the ligament of Treitz is key to the further diagnostic evaluation. Hematemesis confirms an upper GI source, and suggests loss of more than a quarter of blood volume. Melena (black, tarry stool) also comes from an upper source unless the bleeding is brisk or large volume and transit is rapid. Melena without hematemesis usually results from a lesion distal to the pylorus (e.g., duodenal ulcer) or to slow bleeding. Tarry stools may be produced by as little as 100 mL of blood. Lower sources produce hematochezia (maroon or clots from the right colon and bright red from the left colon). A small amount of blood only on the toilet tissue nearly always comes from a bleeding hemorrhoid or fissure. Silver stool is said to arise from acholic stools combined with luminal bleeding in an ampullary cancer.

Determine the hemodynamic significance of the bleeding by looking for postural lightheadedness or changes in pulse or blood pressure. Early symptoms of thirst and lightheadedness occur with loss of more than 15% of intravascular volume. An orthostatic blood pressure drop of 10 mm Hg indicates a loss greater than or equal to 20% of volume. Shock with hypotension and pallor develops with 25% to 40% volume loss.

Stools may be falsely colored by ingestants such as bismuth subsalicylate, iron, licorice or charcoal, which turn it black, or beets, which turn it red. These stools are not sticky. A negative stool test for occult blood will usually resolve this.

Hemoccult screening detects blood loss down to 1 to 10 ml/day. Evaluation of a heme positive stool will reveal colon cancer in 5% to 14% of patients, and large adenomatous polyps in another 15% to 35%. Any single positive stool should be evaluated. Hemoccult screening reduces colon cancer mortality by 15% to 33%. An asymptomatic patient with a negative Hemoccult has only a 0.2% chance of having colon cancer (compared with 1.4% prevalence in this population). Using Hemoccult alone as a screening strategy will miss 50% to 60% of colon cancers.

Clinical Findings

Peptic ulcer disease  Burning or gnawing pain in the epigastrium, relieved by food intake or antacids, often precedes the bleeding episode.

Gastritis  Epigastric tenderness, pain increased by food intake, nausea, bad breath, and a furred, tooth-indented tongue are clues. Use of alcohol or NSAIDs (including aspirin) predispose patients to gastritis.

Mallory-Weiss tear  Protracted vomiting with retching precedes the bleeding, often with frank hematemesis.

Esophageal varices  Presenting with abrupt, painless, often massive, bleeding, esophageal varices are accompanied by spider angiomata, ascites, prominent abdominal venous pattern, and gynecomastia. There will be a history of cirrhosis, chronic liver disease, or alcoholism.

Esophagitis  Bleeding is preceded by recent-onset pain and burning with swallowing.

Epistaxis  Brisk posterior epistaxis with swallowed blood can cause melena.

Esophageal cancer  Suspect cancer when dysphagia (food sticking) and weight loss or right supraclavicular adenopathy is present.

Gastric cancer  It simulates peptic ulcer disease, but weight loss and weakness are progressive and more prominent. A vague epigastric mass may be palpated. Left supraclavicular adenopathy, abdominal mass, and nodular liver, indicative of advanced disease, are often present at diagnosis.

Infectious diarrhea  Bloody diarrhea with cramping abdominal pain occurs mostly in invasive infections, such as Salmonella, Shigella, Campylobacter, enterohemorrhagic E. coli, amebiasis, and C. difficile colitis.

Diverticular bleeding  The typical presentation will be painless and brisk bleeding (maroon stools) in an older patient with known diverticular disease.

Hemorrhoids  Bright red blood coats the stool and toilet tissue. If the patient is examined acutely, a hemorrhoid with an erosion can usually be seen on direct inspection or anoscopy.

Anal fissure  In young adults, bright red blood on the toilet tissue but not admixed with stool, combined with pain when passing a bowel movement strongly suggest a fissure. If the fissure can be visualized, the diagnosis is certain. Care must be taken to stretch the anal skin folds in a circumferential fashion to visualize the whole surface.

Inflammatory bowel disease  Diarrhea, mucous, lower abdominal cramping, urgency, tenesmus, and systemic symptoms such as fever suggest this diagnosis. Erythema nodosum and pyoderma gangrenosum are helpful cutaneous clues.

Angiodysplasia  It presents with painless recurrent bleeding in an older patient. Aortic stenosis and renal failure are associated conditions.

Colon cancer  Weight loss and recent change in bowel habits, left supraclavicular adenopathy, nodular liver, acanthosis nigricans, and a rectal shelf mass suggest this diagnosis. The index of suspicion is raised with a family history of colon cancer or adenomatous polyps, or with ulcerative colitis.

Mesenteric ischemia  Abdominal pain out of proportion to examination findings is the usual acute presentation. A substrate of intestinal angina (pain after meals with food avoidance), small bowel diarrhea, vasculopathy, or atrial fibrillation will usually be the major clues.

Aortoenteric fistula  Massive bright red bleeding occurs with abdominal aortic aneurysm or graft.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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