Gastrointestinal Bleeding

Upper vs lower GI bleeding

The ligament of Treitz, where the duodenum joins the jejunum, divides "upper" from "lower".

For a symptom-focused guide to blood from the bottom, see rectal bleeding.

Causes of upper GI bleeding

• Peptic ulcers: the most common cause, linked to H. pylori infection and NSAIDs (ibuprofen, naproxen, aspirin).
• Gastritis and esophagitis: from NSAIDs, alcohol or acid reflux.
• Esophageal varices: enlarged veins in people with cirrhosis; can bleed massively.
• Mallory-Weiss tear: a tear at the lower esophagus after forceful vomiting or retching.
• Cancers of the esophagus or stomach.
• Dieulafoy lesion and vascular malformations.

Causes of lower GI bleeding

• Diverticular bleeding: sudden, painless, large-volume bleeding in older adults with diverticulosis.
• Hemorrhoids and anal fissures: small amounts of bright red blood.
• Colorectal cancer and polyps.
• Inflammatory bowel disease and infectious colitis: bloody diarrhea.
• Ischemic colitis: cramping pain then bloody stool in older adults.
• Angiodysplasia: fragile vessels in the bowel wall.
• Bleeding after polyp removal.
• Small bowel sources: angiodysplasia, tumors, Crohn's disease, Meckel's diverticulum in young people.

Risk factors

• NSAIDs and aspirin
• blood thinners (anticoagulants and antiplatelet drugs) and SSRIs combined with NSAIDs
• H. pylori infection
• heavy alcohol use and cirrhosis
• older age
• kidney disease
• previous GI bleeding

Symptoms of blood loss

Apart from visible blood, significant bleeding causes:

• dizziness or fainting, especially on standing
• fast heart rate and low blood pressure
• pale, cold, clammy skin
• shortness of breath and chest pain
• confusion

Slow, chronic bleeding may cause only tiredness, breathlessness on exertion and pale skin from iron deficiency anemia.

Diagnosis

1. Assessment and stabilization: pulse, blood pressure, and signs of shock come first.
2. Blood tests: hemoglobin, platelets, clotting, kidney function (urea rises in upper GI bleeds), blood group and crossmatch.
3. Risk scores: such as the Glasgow-Blatchford score, help decide who needs admission and urgent endoscopy.
4. Upper endoscopy: within 24 hours for most upper GI bleeds, both to find and treat the source.
5. Colonoscopy: for lower GI bleeding, after bowel preparation.
6. CT angiography: to locate active bleeding when endoscopy is not possible or not yet done.
7. Capsule endoscopy or enteroscopy: for suspected small bowel bleeding.
8. Fecal immunochemical test (FIT): detects hidden blood in stool for screening.

Treatment

Emergency care

• IV fluids and blood transfusion if needed
• stopping or reversing blood thinners when safe, guided by the clotting and cardiac risks
• IV proton pump inhibitors for suspected ulcer bleeding
• vasoactive drugs (octreotide) and antibiotics for variceal bleeding in cirrhosis

Endoscopic treatment

During endoscopy or colonoscopy, doctors can stop bleeding with clips, heat (cautery), injections of epinephrine, or band ligation of varices.

Other procedures

• Angiographic embolization: a radiologist blocks the bleeding vessel through a catheter.
• TIPS procedure for uncontrolled variceal bleeding.
• Surgery if other methods fail.

Preventing rebleeding

• treating H. pylori with antibiotics
• long-term acid suppression when needed
• avoiding NSAIDs, or using them with a protective medicine if essential
• beta-blockers and banding for varices
• removing polyps; treating colitis or cancer
• iron replacement for anemia

Outlook

Most GI bleeding stops on its own or with endoscopic treatment. The risk of serious outcomes is higher in older adults, people with cirrhosis, heart or kidney disease, and those who bleed while in hospital. Finding and treating the cause greatly reduces the chance of recurrence.

Frequently asked questions

What are the signs of a GI bleed?

Signs include vomiting blood or coffee-ground material, black tarry stools, and red or maroon blood from the rectum. Heavy bleeding causes dizziness, fainting, a fast pulse and pale skin. Slow bleeding may cause only tiredness and anemia.

What is the most common cause of upper GI bleeding?

Peptic ulcers are the most common cause, often linked to H. pylori infection or NSAID use. Other causes include gastritis, esophagitis, varices in liver disease and tears from forceful vomiting.

What does black stool mean?

Black, sticky, tar-like and foul-smelling stool (melena) usually means bleeding from the upper GI tract. It needs urgent medical assessment. Iron tablets and bismuth medicines can also turn stool black, but that stool is not sticky or tarry.

Can a GI bleed stop on its own?

Many GI bleeds stop on their own, but the cause still needs to be found and treated because bleeding can return. Heavy or ongoing bleeding needs emergency treatment.