Gastrointestinal Hemorrhage (GI Bleeding)

Upper vs lower GI bleeding

Note: very brisk upper GI bleeding can also cause red or maroon blood from the rectum.

Causes of upper GI bleeding

• Peptic ulcers in the stomach or duodenum, mostly from H. pylori infection or NSAIDs such as ibuprofen and aspirin. The most common cause.
• Esophageal varices: swollen veins from cirrhosis and portal hypertension, which can bleed massively.
• Esophagitis and erosive gastritis.
• Mallory-Weiss tear: a tear at the esophagus-stomach junction after forceful vomiting.
• Stomach and esophageal cancers.
• Vascular malformations such as Dieulafoy lesions.

Causes of lower GI bleeding

• Diverticular bleeding: sudden, painless, often large bleeding in older adults.
• Hemorrhoids and anal fissures: bright red blood on paper or in the toilet.
• Colitis: from infection, inflammatory bowel disease, ischemia or radiation.
• Polyps and colorectal cancer: often slow bleeding causing anemia.
• Angiodysplasia: fragile blood vessels in the bowel wall, more common in older adults and with kidney disease or aortic stenosis.
• Bleeding after polyp removal.

Risk factors

• NSAIDs and aspirin
• blood thinners and antiplatelet drugs
• alcohol and liver disease
• older age
• previous ulcer or GI bleeding
• SSRIs combined with NSAIDs

Symptoms

• visible blood in vomit or stool
• black, tarry stools (melena)
• dizziness, lightheadedness, fainting
• tiredness, shortness of breath and pale skin from anemia
• chest pain in people with heart disease
• belly pain, depending on the cause

Iron supplements and bismuth medicines can turn stools black, but these stools are not sticky or tarry and do not test positive for blood.

Diagnosis

1. Assessment of stability: pulse, blood pressure and signs of shock.
2. Blood tests: hemoglobin, blood type and crossmatch, clotting, kidney and liver function. A raised urea (BUN) suggests upper GI bleeding.
3. Risk scores such as the Glasgow-Blatchford score help decide who needs admission.
4. Upper endoscopy, ideally within 24 hours for upper GI bleeding.
5. Colonoscopy for lower GI bleeding after bowel preparation.
6. CT angiography for active heavy bleeding when endoscopy cannot find the source.
7. Capsule endoscopy or enteroscopy for bleeding from the small intestine.

Treatment

Emergency care

• IV fluids and blood transfusion when hemoglobin is low (often below 7 g/dL, or higher in heart disease)
• correcting clotting problems and reviewing blood thinners
• IV proton pump inhibitors for suspected ulcer bleeding
• antibiotics and octreotide or terlipressin for suspected variceal bleeding in cirrhosis

Endoscopic treatment

During endoscopy or colonoscopy, the doctor can stop bleeding with:

• clips
• heat coagulation
• adrenaline (epinephrine) injection
• band ligation of varices
• hemostatic powder

Other treatment

• Interventional radiology embolization: blocking the bleeding vessel through a catheter
• TIPS for uncontrolled variceal bleeding
• Surgery if other methods fail
• Treating the cause: H. pylori eradication, stopping NSAIDs, treating inflammatory bowel disease, removing polyps or cancer

Outlook and prevention

Most GI bleeding stops on its own or with endoscopic treatment. Risk of death is higher in older people, those with liver disease or serious other illnesses, and with rebleeding. To lower risk: avoid unnecessary NSAIDs, take PPIs if prescribed with NSAIDs or blood thinners, treat H. pylori, limit alcohol, and keep up with colorectal cancer screening.

Frequently asked questions

What are the signs of a GI bleed?

Signs include vomiting blood or coffee-ground material, black tarry stools, or red or maroon blood from the rectum. Slow bleeding may cause only tiredness, breathlessness and pale skin from anemia. Dizziness or fainting signals significant blood loss.

What is the most common cause of GI bleeding?

The most common cause of upper GI bleeding is a peptic ulcer, usually from H. pylori or NSAIDs. The most common cause of significant lower GI bleeding in older adults is diverticular bleeding, while hemorrhoids are the most common cause of minor rectal bleeding.

Is a GI bleed an emergency?

Vomiting blood, black tarry stools, heavy rectal bleeding, or any GI bleeding with dizziness, fainting or a racing heart is an emergency. Call 911 or your local emergency number or go to an ER. Small amounts of bright red blood with hard stools are less urgent but should be checked.

Can a GI bleed stop on its own?

Many GI bleeds, especially diverticular bleeding and minor ulcer bleeding, stop on their own. However, the cause still needs to be found and treated, because bleeding can recur and some causes, such as cancer or varices, are serious.