Gastrointestinal bleeding

Last updated: Sep 07, 2020

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Summary
Gastrointestinal (GI) bleeding is a symptom of conditions that damage the wall GI tract. GI bleeding is categorized into upper GI bleeding (UGIB) and lower GI
bleeding (LGIB) depending on the source of the bleeding relative to the ligament of Treitz. In the majority of cases, bleeding is localized in
the esophagus, stomach, or duodenum (UGIB). LGIB may occur in the rectum, colon, jejunum, and, in rare cases, the ileum. Gastric and duodenal ulcers are
the most common causes; angiodysplasia, inflammatory diseases, and carcinomas can also cause GI bleeding. Depending on the source of the bleeding and
how long the blood remains in the digestive tract, clinical symptoms may include vomiting blood (hematemesis), tarry black stool (melena), and fresh blood in
the stool (hematochezia). Diagnosis includes evaluation of blood loss (e.g., hematocrit) and localization of the source of bleeding (e.g., endoscopy).
Hospitalization is essential to monitor for signs of hemodynamic instability and shock caused by anemia and severe blood loss. The source of bleeding can
often be located and treated simultaneously during endoscopy with injection therapy (e.g., epinephrine) or ligation.
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Etiology
 Upper gastrointestinal bleeding (UGIB)
o ∼ 70–80% of GI hemorrhages [1][2]
o The source of the bleeding is proximal to the ligament of Treitz. 
 Lower gastrointestinal bleeding (LGIB)
o ∼ 20–30% of all GI hemorrhages [2][3]
o The source of the bleeding is distal to the ligament of Treitz (usually in the colon).
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Most common etiologies of GI bleeding [4]

(UGIB) [5] (LGIB) [6]

Erosive or  Peptic ulcer disease (∼  Diverticulosis (∼ 30% of cases) 

[7]
inflammatory 30% of cases)  
 Esophagitis  Inflammatory bowel
 Erosive gastritis and/or disease (IBD), i.e., ulcerative
duodenitis  colitis and Crohn disease
Most common etiologies of GI bleeding [4]

(UGIB) [5] (LGIB) [6]

 Invasive or inflammatory
diarrhea (bacterial
gastroenteritis, due to
e.g., Shigella, EHEC)

 Esophageal varices   Hemorrhoids

 or gastric varices  Ischemia (e.g., ischemic
 Gastric antral vascular colitis, mesenteric ischemia)
ectasia  Arteriovenous malformation
 Dieulafoy lesion  Rectal varices

 Angiodysplasia: a common degenerative disorder of GI vessels

(mostly venous) that can cause GI bleeding in
the stomach, duodenum, jejunum, and colon 
Vascular
 
 [8]
o Associated with age > 60 years, von Willebrand
disease, aortic stenosis, and end-stage renal disease
o Manifests with episodic bleeding (hematochezia) that ceases
spontaneously in > 90% of cases
o Diagnosis usually requires angiography.
o Lesions are usually multiple tortuous dilated vessels, most
commonly located in the right-sided colon (∼ 75%). 

 Esophageal  Colorectal cancer and/or anal

Tumors cancer and/or gastric cancer 
carcinoma   Colonic polyps 

Traumatic  Hiatal hernias   Lower abdominal trauma

or iatrogenic  Mallory-Weiss  Anorectal trauma (e.g.,
syndrome  anorectal avulsion, impalement
 Most common etiologies of GI bleeding [4]

(UGIB) [5] (LGIB) [6]

 Boerhaave syndrome injuries)

 Following open or endoscopic surgery (e.g., anastomotic bleeding

following a gastric bypass) 

 Portal hypertensive
Other causes gastropathy  Anal fissures
 Coagulopathies
See “Differential diagnosis of lower gastrointestinal bleeding in children.”
Bleeding from the upper respiratory tract (e.g., nocturnal nosebleeds) can be mistaken for GI bleeding because the blood can be swallowed and vomited or
appear in the stool as melena. Careful examination and history taking is the key to differentiating respiratory sources of bleeding from GI ones.

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Clinical features
 Anemia due to chronic blood loss
 Acute hemorrhage: signs of circulatory insufficiency or hypovolemic shock
o Tachycardia, hypotension (dizziness, collapse, shock) 
o Altered mental status
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Description Cause

 Vomiting blood, which  Most commonly due to

Hematemesis may be red or coffee- bleeding in the upper GI
ground in appearance tract (e.g., esophagus, stomach) 
 Description Cause

 Black, tarry stool with a  Most commonly due to

Melena
strong offensive odor bleeding in the upper GI tract 

 The passage of bright

red (fresh) blood
through the anus (with
or without stool)
o Colonic bleeding  Most commonly due
Hematochezia : maroon, jelly- to bleeding in the lower GI
like traces of tract (e.g., in the distal colon) 
blood in stools
o Rectal bleeding:
streaks of fresh
blood on stools
Both melena and hematochezia can be caused by either UGIB or LGIB.
Unexplained iron deficiency anemia in men or postmenopausal women should raise suspicion for GI bleeding.
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Diagnostics
In case of hemodynamic instability, hemodynamic resuscitation should be initiated before further diagnostic workup (see “Treatment” below).
Localization of bleeding
 Definitions
o Occult GI bleeding: bleeding in quantities too small to be macroscopically observable (requires chemical tests or microscopic examination to be
detected)
o Overt GI bleeding: macroscopically observable bleeding with accompanying clinical symptoms (e.g., anemia, tachycardia)
 Fecal occult blood test
o May detect small quantities of blood
o Cannot differentiate between UGIB and LGIB [9]
o A positive result should be followed up with endoscopy/colonoscopy.
 Endoscopy
o Colonoscopy: a procedure during which a flexible fiber-optic instrument is passed through the anus to visualize the mucosa of the colon
o Upper endoscopy: a procedure during which a flexible fiber-optic instrument is passed through the mouth to visualize the inner layer of the
upper GI tract up to the duodenal papilla
 o Should be performed within 24 hours of admission [10]
o Used to identify the source of intestinal bleeding (e.g., bleeding vessel, mucosal inflammation)
o Biopsies can be taken for further diagnosis (e.g., colorectal/gastric carcinoma).
o Therapy can be initiated immediately (e.g., epinephrine injection therapy, clipping of a bleeding vessel).
 Nasogastric tube lavage: a procedure in which a nasogastric tube is passed into the stomach and releases small amounts of liquid, which are removed
with other contents of the stomach (e.g., blood in the case of GI bleeding)
o Rule out UGIB.
o Identify the site of bleeding and possibly initiate therapy.
o Blood that is bright red or has a coffee-ground appearance indicates UGIB.
o Results are negative in ∼15% of patients with UGIB.
 Other: If the above diagnostics fail to locate the source of the bleeding, evaluate for small bowel bleeding.
o Radionuclide scan (RBCs labeled with technetium-99) 
o Video capsule endoscopy
o Push enteroscopy 
o Angiography
 Diagnosis of vascular etiologies (e.g., angiodysplasia)
 Localization of the source of bleeding before surgical resection
o Surgery/exploratory laparotomy should be considered after other therapeutic options have failed. [11]

Approach according to the patient's hemodynamic status

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Hemodynamically
Hemodynamically unstable patient
stable patient

 Upper  Nasogastric tube lavage

endoscopy  Upper endoscopy (if negative,
Suspected UGIB   If negative, additional colonoscopy)
perform  In case of massive life-
a colonoscopy. threatening bleeding: angiography
 Hemodynamically
Hemodynamically unstable patient
stable patient

 Colonoscopy  Nasogastric tube lavage

 If negative,  Upper endoscopy
Suspected LGIB  perform  In case of massive life-
an upper threatening bleeding: angiography or
endoscopy. exploratory laparotomy

Forrest classification
The Forrest classification describes the type of lesion seen during endoscopy and helps to evaluate the risk of renewed hemorrhage (without the need for
repeated intervention).
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Risk of recurring
Stage Description
hemorrhage

I Active hemorrhage

Ia Spurting arterial hemorrhage  85–100% of cases

Ib Oozing hemorrhage 25–55% of cases

II Inactive hemorrhage

IIa Lesion with a visible vessel  20–50% of cases

IIb Lesion with an adherent clot  20–40% of cases

IIc Flat lesion covered with hematin  5–10% of cases

 Risk of recurring
Stage Description
hemorrhage

Lesion without active

III 5% of cases
hemorrhage (flat ulcer base) 

Laboratory tests [12]
 CBC: decreased RBCs, possibly decreased platelets 
 Decreased hematocrit, decreased hemoglobin (both may be normal early in acute blood loss 
)
 Decreased serum ferritin and iron
 Liver function test: possibly increased ALT/AST, increased ALP 
 Increased BUN 

Initial management [12]
 Consider elective intubation in patients with altered mental or respiratory state and severe ongoing hematemesis.
 Hemodynamic resuscitation
o In case of hemodynamic instability and/or suspected ongoing bleeding
o IV fluid to normalize blood pressure and heart rate (see “Fluid resuscitation”)
o Transfusion of packed red blood cells in case of massive bleeding (e.g., hemoglobin < 7 g/dL)
 IV proton pump inhibitors (e.g., esomeprazole) 
 Management of anticoagulants
o INR 1.5–2.5: Endoscopic hemostasis is possible.
 o INR > 2.5: Reversal agents should be considered before endoscopy.
If there is any suspicion of GI bleeding, two large-caliber peripheral venous catheters should be inserted and preparations should be made for a
possible blood transfusion.
Interventions to stop bleeding [14][15]
 Endoscopy
o Used to locate the site of the (suspected) bleeding and to initiate therapy 
 Injection therapy (e.g., epinephrine): actively bleeding ulcers or blood vessels
 Hemostatic surgical procedures: sclerotherapy, band ligation, cauterization, or clip placement
 Polypectomy in case of bleeding polyp (e.g., in the colon)
 Angiography: vasoconstriction of a bleeding vessel via e.g., intraarterial vasopressin infusion or embolization
 Surgery (laparotomy): if bleeding cannot be contained through endoscopic intervention (rarely the case) 
Treatment of underlying disease
See “Treatment” sections in “Crohn disease“, “Ulcerative colitis“, “Peptic ulcer disease“, “Hemorrhoids“, “Intestinal ischemia“, “Gastric cancer“, “Colorectal
cancer“, and “Portal hypertension.“
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Differential diagnoses
Upper GI bleed
 Erosive or inflammatory
o Peptic ulcer disease
o Esophagitis
o Erosive gastritis and/or duodenitis
o Zollinger-Ellison syndrome
o Cameron lesion
 Vascular
o Varices (esophageal, gastric, duodenal, ectopic)
o Gastric antral vascular ectasia
o Dieulafoy lesion
o Angiodysplasia
o Angioma
o Osler-Weber-Rendu disease
o Watermelon stomach
o Blue rubber bleb nevus syndrome
o Telangiectasias
 Portal hypertensive gastropathy
  Tumors
o Esophageal cancer
o Gastric cancer
 Traumatic or iatrogenic
o Mallory-Weiss tear
o Hiatal hernia
o Foreign-body ingestion
o During surgery or endoscopy
o Aortoenteric fistula
 Coagulopathies
 Hemobilia
 Hemosuccus pancreaticus
Lower GI bleed
 Erosive or inflammatory
o Diverticular disease
o Ulcerative colitis
o Crohn disease
o Rectal ulcers
o Stercoral ulcer
o Celiac disease
o Proctitis
 Vascular
o Hemorrhoids
o Ischemic colitis
o Mesenteric ischemia
o Arteriovenous malformation
o Rectal varices
o Angiodysplasia
o Small bowel varices
 Tumors
o Colorectal cancer
o Anal cancer
o Colonic polyps
o Gardner syndrome
 Trauma or iatrogenic
 o Anorectal trauma
o Lower abdominal trauma
o During surgery or coloscopy
o Anastomotic bleeding
o Aortoenteric fistula
 Coagulopathies
 Anal fissures
 Brisk UGIB
 Infectious colitis/enteritis
 Radiation-induced colitis
 Fecal impaction
 Meckel diverticulum
The differential diagnoses listed here are not exhaustive.
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Complications
 Hypovolemic shock
 Hepatic encephalopathy (in patients with liver cirrhosis) 
 Aspiration pneumonia 
[16][17]