Causes of Gastrointestinal bleeding and how to prevent them FREE. Self Learn Series 17

Gastrointestinal bleeding refers to any bleeding that originates in the gastrointestinal tract, from the mouth to the large bowel. The degree of bleeding can range from nearly undetectable to acute, massive, life-threatening bleeding. Bleeding may originate from any site along the gastrointestinal tract, but is often divided into Upper GI bleeding (considered any source located between the mouth and outflow tract of the stomach), Lower GI bleeding (considered any source located from the outflow tract of the stomach to the anus, small and large bowel included)

Other Names for GI Bleeding.

Lower GI bleeding; GI bleeding; Upper GI bleeding

Many individuals have small amount of gastrointestinal bleeding ranging from microscopic bleeding, where the amount of blood is so small that it can only be detected by laboratory testing, to massive bleeding where pure blood is passed.

It is important to be aware of gastrointestinal bleeding, because it may herald many significant diseases and conditions. Prolonged microscopic bleeding can lead to massive losses of iron and subsequent anaemia. Acute, massive bleeding can lead to acute hypotension, unconsciousness and even death.

Gastrointestinal bleeding can occur at any age from birth on. The degree and suspected location of the bleeding determines what tests should be performed to find the cause. Once a bleeding site is identified, numerous therapies are available to stop the bleeding.

Diagram 1, below shows the main parts of the GI tract which are likely to bleed.

Diagram 1. Parts of the GI tract which are most likely to bleed.

Causes of Upper Gastrointestinal bleeding.

GI Bleeding is divided into two types, for the purposes of this article, bleeding which occurs in any part of the GI tract from the mouth to the outflow tract of the stomach, is called upper GI Bleed. The causes of upper GI bleeding are different from those of lower GI bleed which will be discussed later.Upper GI bleeding

1. Peptic Ulcer disease and peptic ulcer are localized erosions of the wall of the stomach. Ulcers in this region are a frequent occurrence. The breakdown of the walls results in damage to blood vessels, causing bleeding, which may be microscopic of massive. When the mucous membranes break down, they are unable to counteract the harsh effects of stomach acid. Nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, alcohol, and cigarette smoking promote gastric ulcer formation. These are the most common causes of GI bleeding. Some types of bacteria also promote formation of ulcers.
2. General inflammation of the stomach wall, which can result in bleeding. Gastritis also results from an inability of the gastric lining to protect itself from the acid it produces. NSAIDs, steroids, alcohol, and trauma can cause gastritis.
3. Esophageal varices: Swellings in veins of your esophagus or stomach usually result from liver disease. Varices most commonly result from alcoholic liver. When varices bleed, the bleeding can be massive and catastrophic and occur without warning.
4. Mallory-Weiss tear: A tear in the esophageal or stomach wall, often as a result of vomiting or retching. Tears also can occur after seizures, forceful coughing or laughing, lifting, straining, or childbirth. Physicians often find tears in people who have recently binged on alcohol.
5. Clot Busting medications used in the treatment / management of myocardial ischaemia, coronary artery occlusion, cerebral ischemia / occlusion can cause massive bleeding in the GI system.
6. Steroids like prednisolone can induce bleeding in some patients.

Causes of Lower Gastrointestinal bleeding.

1. Diverticula are one of the most common causes of lower GI bleeding. Small out-pockets, or diverticula, form on part of the wall of your colon (large intestine), usually in a weakened area of the bowel wall. Any individual can develop several pockets, which are more common in people who have and strain at stool.
2. Angiodysplasia: This is one of the most common causes of lower GI bleeding. Angiodysplasia is a malformation in the blood vessels in the wall of the GI tract. The sores are most common in the large intestine and often bleed. The elderly and people with chronic develop the disease most often but this does not exclude ordinary individuals developing them.
3. Intestinal polyps are noncancerous tumors of the GI tract, occurring mostly in people older than 40 years. A small proportion of these polyps may transform into Colonic polyps may bleed rapidly, or they may bleed slowly and go undetected.
4. Haemorrhoids and fissures: are swellings of veins in and around your rectum. Repeated stretching from straining at stool causes them to bleed. Bleeding from hemorrhoids is usually mild, intermittent, and bright red. Massive bleeding is rare. Anal fissures, or tears in the anal wall, also may trigger small amounts of bright red bleeding from the anus. Forceful straining during passage of hard stool usually causes such tears, which can be very painful.

Picture 1 Sengstaken-Blakemore tube is inserted in the oesophagus and inflated to apply pressure on the bleeding varicose veins.

Signs and Symptoms of Gastrointestinal bleeding

Severe, Acute gastrointestinal bleeding will first, most likely appear as vomiting of blood. Sometimes, bloody bowel movements, or black, tarry stools with a characteristic smell may be present. The Blood in the stool will have changed and will look like “coffee grounds.” Symptoms associated with blood loss can include the following:

1. Many patients often complain of fatigue. This is due to the fact that the blood loss is making the patient tired and exhausted.
2. Weakness is another sign associated with GI bleeding. The reasons for this symptom are the same as for the reason stated above.
3. Many patients with GI bleeding complain of Shortness of breath. This is because there is insufficient blood to transport oxygen to the lungs and the heart.
4. GI bleeding causes the patient to loose blood in the GI tract. The loss of blood is not known to the patient because, most of the time he/she does not see or feel it. The pink colour of the patient’s face disappears. He/she therefore appears pale.hortness of breath
5. Some patient will vomit blood, This is most likely to occur if the bleeding is originating from an upper GI source. Bright red or maroon stool can be from either a lower GI source or from brisk bleeding at an upper GI source.
6. Sometimes, long-term GI bleeding may go unnoticed or may cause fatigue because it usually occurs slowly. In such cases black stools, or a positive test for microscopic blood will confirm the diagnosis of GI bleed.
7. False positive results will be obtained if the patient consumes red meat prior to doing the test.

Diagnosis of GI Bleeding.

GI bleeding can be an emergency condition requiring immediate medical attention. fluids and medications, blood transfusions, drainage of the stomach through a tube (nasogastric tube), and other measures or it may be an inconvenience which requires minor medical intervention. If unattended, it can get worse and lead to an acute condition which can cause death. Once the condition is stable, a physical examination, including a detailed abdominal examination, should be performed.

Presentation & History: The site of the bleeding must be located. A complete history and physical examination are essential and should be done as soon as possible. Symptoms such as changes in bowel habits, stool color (to black or red) and consistency, and the presence of pain or tenderness may tell the treating physicain which area of the GI tract is affected. Because the intake of iron or foods such as beets can give the stool the same appearance as bleeding from the digestive tract, a doctor must test the stool for blood before offering a diagnosis. A blood count will indicate whether the patient is anemic and also will give an idea of the extent of the bleeding and how chronic it may be.

Endoscopic Examination: It is a common diagnostic technique that allows direct viewing of the bleeding site. The endoscope can detect lesions and confirm the presence or absence of bleeding, doctors often choose this method to diagnose patients with acute bleeding. In some cases, the doctor can use the endoscope to treat the cause of bleeding, as well, when he/she is doing the examination.

The endoscope is a flexible instrument which is inserted through the mouth or rectum. The instrument allows the doctor to see the bleeding point in the esophagus, stomach, duodenum (esophago-duodenoscopy), colon (colonoscopy), and rectum (sigmoidoscopy); to collect small samples of tissue (biopsies); to take photographs; and to stop the bleeding.

Small bowel endoscopy, or enteroscopy, is a relatively new procedure using a long endoscope. This endoscope may be introduced during surgery to localize a source of bleeding in the small intestine. Our small intestine is about 30 feet long and it is difficult to thread it all the way from the mouth to the anus.

Barium X-rays is another method available to locate the source of bleeding. Barium x-rays, in general, are less accurate than endoscopy in locating bleeding sites. Some drawbacks of barium x-rays are that they may interfere with other diagnostic techniques if used for detecting acute bleeding; they expose the patient to x-rays; and they do not offer the capabilities of biopsy or treatment.

Angiography is a technique that uses dye to highlight blood vessels. This procedure is most useful in situations when the patient is acutely bleeding such that dye leaks out of the blood vessel and identifies the site of bleeding. In selected situations, angiography allows injection of medicine into arteries that may stop the bleeding immediately. Therefore, this examination sometimes turns into treatment.

Radionuclide scanning is a noninvasive screening technique used for locating sites of acute bleeding, especially in the lower GI tract. This technique involves injection of small amounts of radioactive material. Then, a special camera produces pictures of organs, allowing the doctor to detect a bleeding site relatively easily.

An additional benefit of barium x-rays, angiography, and radionuclide scans is that these tests can be used to locate sources of chronic occult bleeding. These techniques are especially useful when the small intestine is suspected as the site of bleeding since the small intestine may not be seen easily with endoscopy.

Treatments of GI Bleeding.

Endoscopic Cauterization. The use of endoscopy has grown and now allows doctors not only to see bleeding sites but to directly apply therapy as well. A variety of endoscopic therapies are useful to the patient for treating GI tract bleeding. Cauterizing the bleeding vessel is a common intervention.

At other times, active bleeding from the upper GI tract can often be controlled by injecting chemicals directly into a bleeding site with a needle introduced through the endoscope. A physician can also cauterize (as stated above), or heat treat, a bleeding site and surrounding tissue with a heater probe or electrocoagulation device passed through the endoscope. Laser therapy, although effective, is no longer used regularly by many physicians because it is expensive and cumbersome. May still be used in some special situations

When acute bleeding is under control, medicines are often prescribed to prevent recurrence of bleeding. Medical treatment of ulcers to ensure healing and maintenance therapy to prevent ulcer recurrence can also lessen the chance of recurrent bleeding. Studies are now under way to see if elimination of Helicobacter pylori affects the recurrence of ulcer bleeding.

Removal of polyps with an endoscope can control bleeding from colon polyps. Removal of hemorrhoids by banding or various heat or electrical devices is effective in patients who suffer hemorrhoidal bleeding on a recurrent basis. Endoscopic injection or cautery can be used to treat bleeding sites throughout the lower intestinal tract.

Endoscopic techniques do not always control bleeding. Sometimes angiography may be used. However, surgery is often needed to control active, severe, or recurrent bleeding when endoscopy is not successful. Treatment is always individualized for the patient.

Use of ice cold water to stop acute bleeding is the stomach may be attempted is some situations.

Sangsten blakemore tube may be inserted into the esophagus to apply pressure on the bleeding varices in the esophagus.

This article is for nursing information only. It is not to be used for diagnosis and / or treatment.