Definition

Gastrointestinal bleeding is a symptom that indicates a disorder of the digestive tract and is typically categorized into upper gastrointestinal bleeding and lower gastrointestinal bleeding. The upper digestive tract refers to the area from the mouth to the small intestine, specifically the duodenum, located at the ligament called Treitz's ligament. The lower digestive tract is situated below Treitz's ligament. Approximately 75% of gastrointestinal bleeding originates from the upper digestive tract.

Causes

Upper gastrointestinal bleeding (UGIB) can be caused by various problems, with the most common being peptic ulcers, accounting for 40-50% of UGIB cases. Peptic ulcers are often related to infection with Helicobacter pylori bacteria, which disrupts the lining of the stomach and causes inflammation in stomach cells. As the ulcer deepens, the walls of the blood vessels become thinner, eventually leading to rupture and bleeding.

In addition to ulcers, bleeding can occur due to vomiting. Forceful contractions of the muscles in the esophagus and stomach during vomiting can tear the inner lining of these organs, resulting in bleeding. Forceful vomiting and severe coughing can also cause tears in the upper part of the stomach, near the junction between the esophagus and the stomach, known as Mallory-Weiss tears.

Inflammation in the upper gastrointestinal tract, including the esophagus, stomach, or small intestine, can also lead to bleeding. Varices, which are enlarged veins in the esophagus, can increase the risk of gastrointestinal bleeding. Varices are often caused by chronic liver disease or cirrhosis, which leads to elevated blood pressure in the liver blood vessels.

Stress-induced ulcers can also cause gastrointestinal bleeding. Stress in this context refers to conditions such as shock (organ failure leading to unstable body condition), severe trauma, acute respiratory failure, acute kidney failure, and sepsis (bacterial infection causing an extreme immune system response). These ulcers occur due to reduced blood flow to the stomach and changes in stomach acidity.

Other causes of UGIB include the long-term use of painkillers or aspirin, which suppress the production of prostaglandins, thereby compromising the stomach's immune system. Additionally, disorders of blood vessels near the stomach can also increase the risk of UGIB.

Risk factor

The risk factors for UGIB include the long-term use of painkillers, aspirin, and clopidogrel. Aspirin and clopidogrel are commonly prescribed to individuals with a history of heart stent placement, heart attack, or stroke. Additionally, the risk of bleeding is higher in individuals with chronic liver disease, such as chronic hepatitis B, hepatitis C, and liver cirrhosis.

Furthermore, hospitalized patients, particularly those in intensive care units, are at a high risk of UGIB due to their often unstable condition, which can lead to stress-induced ulcer formation.

Symptoms

The symptoms of upper gastrointestinal bleeding (UGIB) may include vomiting blood that is either bright red or dark, passing dark or black stools, and having bloody stools. Additional symptoms can include fainting, upper abdominal pain, chest pain or a burning sensation, abdominal pain with an unclear location, difficulty swallowing, weight loss, and jaundice (yellowing of the skin and eyes).

These symptoms may also indicate undetected gastrointestinal bleeding or other conditions that can cause UGIB. In cases of significant bleeding, hypotension or a decrease in blood pressure may occur.

Diagnosis

Upper gastrointestinal bleeding often constitutes a medical emergency. Initial assessment focuses on ensuring clear airways, regular and adequate breathing, and good blood circulation. Vital signs such as pulse rate, respiratory rate, temperature, and blood pressure are examined to determine the urgency of initial management. If the patient is stable and conscious, blood pressure is measured in three positions to detect any differences that may have contributed to fainting. Abdominal examination may be conducted to ascertain the location of pain and any palpable tenderness. Additionally, a rectal examination may be performed to assess anal muscle function and check for the presence of blood, mucus, or abnormal stool color.

Laboratory examinations are crucial in assessing the severity of bleeding. A complete blood test determines hemoglobin levels, and blood typing and crossmatching may be done as a precaution for potential blood transfusion. Other tests may include assessing blood urea, electrolyte levels, and blood clotting time. In some cases, a urease test can detect urea products in the stomach, which may indicate Helicobacter pylori infection, though this is not definitive. Occult blood tests on stool samples may also be conducted if bleeding complaints are absent.

To rule out other diagnostic possibilities, electrocardiography may be performed, as symptoms of chest pain can be difficult to differentiate from cardiac issues.

Imaging studies may be employed to support diagnosis. Chest X-rays can assess the chest for possible respiratory tract involvement. CT scans and ultrasound can help identify the bleeding source and potential causes. Endoscopy, if available, is a valuable option for imaging. This procedure involves inserting a camera-equipped tube through the mouth to visualize the esophagus, stomach, and small intestine, providing a clear view of the bleeding source. However, endoscopy is typically performed only after the patient's condition stabilizes.

Management

The immediate treatment for GI bleeding involves establishing an intravenous (IV) line and administering fluids as a top priority to maintain stable blood pressure. In cases where the patient is short of breath or vomiting large amounts of blood, intubation (placing a breathing tube) may be necessary to ensure an open airway.

If the hemoglobin level is too low, a blood transfusion may be performed until it reaches an adequate level. The threshold for transfusion varies, with higher levels recommended for elderly patients and those with a history of heart disease compared to normal individuals.

For bleeding not caused by esophageal varices, medications to reduce stomach acid may be administered. Initially, these medications are given through injection, and upon discharge, they are continued orally. However, if the bleeding is due to varices, medications are used to stop the bleeding.

Endoscopy can play a therapeutic role. In certain cases, the bleeding site can be clipped, cauterized with heat, or injected with medication under endoscopic guidance.

In instances where Helicobacter pylori infection is identified as the cause of upper gastrointestinal bleeding, antibiotics may be prescribed to eradicate the bacteria. Additionally, medications like bismuth may be administered to protect the inner lining of the stomach, promoting faster healing.

Complications

Complications of GI bleeding include shock, anemia, and death. Shock or organ failure often occurs due to excessive bleeding, resulting in inadequate blood volume to effectively deliver oxygen to the tissues. Shock is typically characterized by cold hands and feet, an increased pulse rate, decreased blood pressure, and, in severe cases, restlessness, indicating impaired consciousness.

Prevention

Upper gastrointestinal bleeding can be prevented by limiting the use of pain relievers if not absolutely necessary or prescribed by a doctor, reducing alcohol consumption, and quitting smoking. Additionally, individuals with gastroesophageal reflux disease (GERD) should follow their doctor's instructions to manage the condition effectively.

When to see a doctor?

If you or someone around you vomits blood or experiences prolonged black stools or bloody stools, seek medical attention immediately. Additionally, if signs of shock such as low blood pressure, prolonged absence of urination, rapid (and possibly weak) pulse rate, or changes in consciousness such as sleepiness, restlessness, or unconsciousness are observed, take them to the nearest Emergency Department without delay.

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