What is Gastrointestinal Bleeding (GI bleed)?
Gastrointestinal bleeding, or bleeding in the digestive system, can come from two main regions: the upper and lower areas. The distinction between an upper and a lower bleed is determined by a specific anatomical point called the ligament of Treitz (or the suspensory ligament of the duodenum). This is a tissue structure that holds the top part of the small intestine up inside the belly. If the bleeding comes from above this ligament, it usually results in hematemesis or melena. On the other hand, bleeding from below this point is often noticed as hematochezia.
Hematemesis is when someone vomits blood or blood mixed with stomach contents. Melena refers to dark, smelly, and sticky feces that are black in color. This is due to the action of digestive enzymes and intestinal bacteria on blood. Finally, hematochezia is when bright red blood is visible in the stool or when going to the bathroom through the rectum.
What Causes Gastrointestinal Bleeding (GI bleed)?
The source of gastrointestinal, or GI, bleeding can either be in the upper or lower part of the GI tract.
Bleeding in the Upper GI Tract:
– Peptic ulcers, which could be caused by too much stomach acid, H. pylori bacteria, overuse of certain medications like NSAIDs, or stress
– Inflammation of the esophagus (esophagitis) and of the stomach and upper part of the intestine (gastritis and duodenitis)
– Swollen blood vessels (varices)
– An increased pressure in the blood vessels of the stomach due to liver disease (portal hypertensive gastropathy)
– Abnormal blood vessels (angiodysplasia)
– Dieulafoy lesion, or a bleeding, enlarged blood vessel that goes through the lining of the GI tract
– Gastric antral valvular ectasia, also known as watermelon stomach
– Tears in the lining of the esophagus or stomach (Mallory-Weiss tears)
– Cameron lesions, or bleeding ulcers at the site of a hiatal hernia
– Connection (fistulas) between the aorta, a large blood vessel, and the intestines
– Swallowed Foreign objects
– Bleeding after surgeries, such as after the removal of a polyp
Bleeding from the bile duct (hemobilia), the pancreatic duct (hemosuccus pancreaticus), and tumors in the upper GI tract can also cause bleeding.
Bleeding in the Lower GI Tract:
– Diverticulosis, where the wall of the colon forms a pouch next to a blood vessel; this can get damaged over time and bleed
– Abnormal blood vessels (angiodysplasia)
– Infection of the colon (infectious colitis)
– Lack of blood flow to the colon (ischemic colitis)
– Inflammatory bowel disease
– Colon cancer
– Hemorrhoids
– Tears in the skin of the anal canal (anal fissures)
– Swollen blood vessels in the rectum (rectal varices)
– Dieulafoy lesion, although this is more often found in the stomach
– Damage due to radiation treatment for abdominal or pelvic cancers
– Post-surgery bleeding, such as after the removal of a polyp or a biopsy.
Risk Factors and Frequency for Gastrointestinal Bleeding (GI bleed)
Upper gastrointestinal bleeding, or UGIB, occurs more frequently than lower gastrointestinal bleeding, or LGIB. For every 100,000 people, about 67 experience UGIB while around 36 experience LGIB. LGIB tends to be more prevalent in men, likely due to a higher incidence of vascular diseases and diverticulosis in the male population. The chances of experiencing these conditions also increase with age. However, these kinds of bleeding are becoming less common across the nation.
Signs and Symptoms of Gastrointestinal Bleeding (GI bleed)
When speaking to a patient with potential stomach (gastrointestinal or GI) bleeding, it’s essential to ask the right questions. These could be about:
- Previous instances of GI bleeding
- Past health issues related to the possible sources of bleeding (including varices, high blood pressure in the liver, alcohol or tobacco use, stomach ulcers, Helicobacter pylori infection, diverticulitis, hemorrhoids, inflammatory bowel disease)
- Other health conditions that may affect treatment
- Meds that may contribute to or complicate the bleeding (like non-steroidal anti-inflammatory drugs, anticoagulants, antiplatelet agents, bismuth, iron)
- Symptoms related to the bleeding (for instance, painless or painful defecation, difficulty swallowing, unexplained weight loss, frequent vomiting or retching, change in bowel movement habits)
During the physical examination of the patient:
- Look for signs of unstable heart function due to blood loss:
- If the patient has a fast resting heartbeat, it may suggest that they’ve lost less than 15% of their total blood volume.
- If the patient’s blood pressure drops when they stand up, it could mean they’ve lost approximately 15% of the total blood volume.
- If the patient’s blood pressure is low even when lying down, it might indicate a loss of around 40% of total blood volume.
- Abdominal pain might indicate a hole (perforation) or insufficient blood supply (ischemia) in the stomach.
- Perform a rectal exam to check for:
- Anal fissures or small tears
- Hemorrhoids or swollen veins in the rectum
- Anorectal mass or growth
- Stool examination
Testing for Gastrointestinal Bleeding (GI bleed)
Several laboratory tests can help doctors identify the source of gastrointestinal (GI) bleeding. These tests include a complete blood count, checking your hemoglobin and hematocrit levels, International Normalized Ratio (INR), prothrombin time, activated partial thromboplastin time, lactate, and liver function tests.
Doctors can also use visual inspection tools to directly observe different parts of your digestive system, pinpoint the source of bleeding, and potentially treat it. Procedures such as an upper GI endoscopy allow doctors to see and treat the upper part of your gut, which includes everything from your mouth to the beginning of your small intestine (called the ‘duodenum’). Similarly, a lower GI endoscopy or colonoscopy lets doctors examine and treat your lower gut, which includes your colon and the end of your small intestine (the ‘terminal ileum’).
In some cases, doctors might need to look further into your small bowel. This can be done using push enteroscopy or deep small bowel enteroscopy.
Nuclear scintigraphy, also known as a tagged Red Blood Cell (RBC) scan, can identify bleeding occurring at a rate of 0.1 to 0.5 mL per minute using a radioactive material called technetium-99m. However, this method will only work if bleeding is currently happening. It can also assist in narrowing down areas for surgical intervention and angiography.
If a bleeding vessel needs to be identified, a CT angiography or standard angiography can be performed. However, for standard angiography, the bleeding needs to be at a rate of 0.5 to 1.0 mL per minute for the bleeding source to be seen.
Lastly, If ectopic gastric mucosa (an unusual presence of stomach lining) needs to be located, specifically in a rare condition known as Meckel’s diverticulum, a special nuclear medicine scan called a Meckel scan can be performed.
Treatment Options for Gastrointestinal Bleeding (GI bleed)
In simple words, the treatment of acute gastrointestinal (GI) bleeding involves evaluating your health status, then administering supportive therapy and figuring out the root cause of the bleeding.
Depending on the seriousness of your condition, healthcare professionals use tools such as the AIMS65 score, the Rockall score, and the Oakland score to decide if you should get treatment in an Intensive Care Unit (ICU), on a general medical ward or at home.
If your condition is critical (you have unstable vital signs, constant bleeding, or high chances of other health problems), healthcare professionals might admit you to the ICU for close monitoring and emergency treatment.
If your condition is less grave and you are more stable, you’ll be treated in a general medical ward. However, it’s still beneficial to monitor your heart rhythm continuously for any possible complications.
In some cases, if you’re young and healthy and your bleeding is not causing symptoms and is under control, healthcare professionals might decide to discharge you from the hospital. Then you’ll receive treatment as an outpatient.
When getting treated, you will need to avoid eating or drinking anything in certain cases. If you’re having a hard time breathing, supplemental oxygen will be provided. It is important to remember that you may need to receive breathing assistance in a controlled manner if you’re throwing up continuously, to reduce the risk of aspiration – inhaling food or liquid into the lungs.
You will be connected to an IV (intravenous drip) to allow delivery of fluids, restore hydration and make blood transfusions more efficient.
Blood transfusions may be necessary if your hemoglobin levels or platelet counts are low. Prothrombin complex concentrate is administered if your blood’s clotting time (INR) is high.
Depending on the source of your GI bleed, healthcare professionals might give you proton pump inhibitors (PPIs) and prokinetic agents – medications to control stomach acid and improve visualization for testing respectively. Other medications given include vasoactive medicines to reduce bleeding and antibiotics if needed.
If you’re already taking blood-thinner medications, healthcare professionals may recommend suspending them until the bleeding is controlled.
If there’s a lot of fresh blood or clots in your stomach, they may have to be removed to facilitate scope procedures (endoscopy).
If your bleeding is massive and uncontrolled or if you’re unstable, specific emergency interventions might be required. These would include placing tubes (known as Blakemore or Minnesota tubes) into your stomach or even considering surgery if absolutely necessary.
If the source of your lower GI bleed is from diverticulum or angiodysplasia (abnormal blood vessels), procedures using a special heat probe, injecting medicine to promote clotting, or applying tiny metal clips to stop the bleeding might be provided.
What else can Gastrointestinal Bleeding (GI bleed) be?
When doctors diagnose gastrointestinal (GI) bleeding, they must consider other health issues that may look alike. The following circumstances could mirror symptoms of GI bleeding.
Sometimes, coughing up blood can be mistaken for vomiting blood, or the other way around. Eating products containing bismuth or taking iron supplements can darken your stools, mimicking a symptom of GI bleeding. Also, some foods or food colorings can change the color of your vomit or stool to red, purple, or maroon. For instance, eating beets can cause this color change.
The medical team would also look at the following conditions that may be causing upper GI bleeding:
- Stomach or duodenal ulcers
- Inflammation of esophagus, stomach, or duodenum
- Swollen veins in the esophagus or stomach
- Diseases related to high blood pressure in the liver
- Abnormal blood vessels
- Rare, severe stomach bleeding causing lesions
- Stomach lining tears after heavy vomiting or retching
- Bleeding from foreign substances swallowed
- Upper GI cancers
- Blood in bile due to liver diseases
- Bleeding from the pancreas
And the following conditions that could be linked with lower GI bleeding:
- Bulging pockets in the colon wall
- Abnormal blood vessels
- Infections causing inflammation in the colon
- Reduced blood flow to the colon
- Diseases causing long-term inflammation of the gut
- Colon cancer
- Hemorrhoids
- Anal tears
- Swollen veins in the rectum
- Damages to the colon lining due to radiation therapy
To help make a correct diagnosis, the doctor will take a careful history and may carry out physical tests.
What to expect with Gastrointestinal Bleeding (GI bleed)
There aren’t many studies on what happens after gastrointestinal (GI) bleeding occurs. However, what we do know from the available studies is that about 10% of people tend to die in the hospital from upper GI bleeding. This rate remains the same even one month after leaving the hospital. Patients followed three years after having this condition showed about 37% had died due to various causes.
Interestingly, women had higher chances of mortality than men in cases of upper GI bleeding, which is a contrast to lower GI bleeding. Patients who have been hospitalized more than once for GI bleeding also show higher rates of mortality. The worst outcomes were seen in patients who also had cancers and vein bleeding. As with many conditions, older age predicted worse outcomes.
On the other hand, lower GI bleeding tends to have lower in-hospital mortality rates, less than 4%. More often, death was linked to other pre-existing conditions rather than the bleeding itself. Older age, other medical diseases, and disrupted blood flow to the gut increased the chances of death. Patients who started bleeding while already in the hospital for something else, those with blood clotting disorders, needing a blood transfusion, or were male also showed worse outcomes. However, those who had lower GI bleeding due to more harmless causes like hemorrhoids, anal fissures or colon polyps showed the lowest mortality rates. Long-term studies following up on patients with lower GI bleeds are quite rare.
Possible Complications When Diagnosed with Gastrointestinal Bleeding (GI bleed)
If gastrointestinal bleeding isn’t addressed promptly and correctly, it can result in severe outcomes. Here are some complications that can happen if a person has upper or lower gastrointestinal bleeding:
- Difficulty in breathing
- Heart attack
- Infections
- Shock
- Potential death
Preventing Gastrointestinal Bleeding (GI bleed)
If you have peptic ulcer disease and the bacteria H pylori is detected, your doctor may recommend a treatment to eliminate this bacteria as it helps lower the chances of subsequent episodes of bleeding ulcers. It’s best to avoid anti-inflammatory medications like NSAIDs, which can increase the risk of ulcer bleeding. However, if these medications are unavoidable, then it’s suggested to use the minimum amount for the shortest time.
In this situation, COX-2 inhibitors, which have a lower risk for causing ulcer bleeding, can be a safer option. Additionally, your doctor might also recommend medicines called Proton-pump inhibitors (PPIs) or misoprostol to be taken alongside NSAIDs to help protect your stomach.
Participating in regular physical activity can help prevent the worsening of another condition known as diverticular disease. However, the usage of Aspirin and NSAIDs could increase the risk of complications related to this condition, such as diverticulitis and diverticular bleeding.
