Gastrointestinal Bleeding (Abdominal Pain)

Abdominal pain is the main indication in this situation. Gastrointestinal bleeding can be classified as upper gastrointestinal bleeding and lower gastrointestinal bleeding.

Clinical Features of GI Bleeding

• Black colored stools called as Malena
• Blood in vomitus or coffee colored vomitus
• Blood mixed with feces
• Abdominal pain
• Pallor and increased pulse rates
• Feeling of tired
• Shortness of breath and feeling faintish

Types of Gastrointestinal Bleeding

• Upper Gastrointestinal Bleeding
• Lower Gastrointestinal Bleeding

Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding is due to lesions that occur in part of gastrointestinal tract which is proximal to right colon.

Causes for Upper Gastrointestinal Bleeding

• Peptic ulceration
• Drugs like NSAIDS, Aspirin
• Gastrointestinal carcinoma
• Gastric erosions
• Varices which occur due to chronic liver cell disease

Lower Gastrointestinal Bleeding

Lower gastrointestinal bleeding is due to lesions in the part of gastrointestinal tract distal to right colon.

Causes for Lower Gastrointestinal Bleeding

• Hemorrhoids
• Anal fissures

Long-term gastrointestinal bleeding can be due to carcinoma of colon, polyps in colon, colitis as Crohn’s disease, ulcerative colitis and infective conditions.

Risk Assessment

If the patient is presenting with gastrointestinal bleeding it is very important to assess the risk of re bleeding and death.

The factors that increase the risk of bleeding are;

• The age

• Evidence of other co- morbidities as cardiac failure, ischemic heart disease, chronic kidney disease and malignant disease,

• Presence of classical clinical features of shock as pallor, cold peripheries, tachycardia and low blood pressure

• Signs of chronic liver disease and endoscopic evidence of tears in esophagus and peptic ulcers.

Diagnosis

Diagnosis can be done by assessing the patient through history and examination. The other investigations that can be used are upper gastrointestinal endoscopy, colonoscopy, unprepared CT, capsule endoscopy and CT colonography.

Management in Emergency Treatment Unit

• If it is a sudden onset bleeding, management should include initial assessment through history and examination while notifying any co morbidities,
• Monitoring pulse and blood pressure once in half and hours
• Taking blood for investigations as hemoglobin, urea, electrolytes, liver biochemistry, blood grouping, coagulation and cross matching
• Establishing intravenous access through two large bore cannulas,
• Giving blood if necessary
• Giving oxygen therapy and doing urgent endoscopy in patients who are having shock.

Long-term Management

• During endoscopic interventions varices should be treated with banding, bleeding ulcers should be treated with hemostatic methods as injection with adrenaline and thermal coagulation.
• Also during endoscopy it is important to take antral biopsies to asses for bacteria as H.pylori.
• As drug therapy an IV proton pump inhibitor as Omeprazole can be given for patients with actively bleeding ulcers or ulcers with visible vessels.
• If the patient is having a chronic bleeding it is important to diagnose whether the patient is suffering from iron deficiency anemia which indicates as reduced hemoglobin in blood. Chronic GI bleeding accounts for the cause of iron deficiency anemia in all men and women after menopause. Oral iron can be given although intravenous infusions are occasionally required.
• Some patients will require maintenance with regular blood transfusion as a last resort.
• Also finding the cause for the chronic bleeding and treating it appropriately is the main step in management of chronic bleeding.

The patient’s age, diagnosis on endoscopy, co-morbidity, presence or absence of shock and availability of social support are few of the factors that must be taken in to account when discharging a patient after assessing in the ward for gastrointestinal bleeding.

References

• Kumar and Clerk’s Clinical Medicine -8th Edition- Parveen Kumar, Michael Clark
• Oxford Handbook of Clinical Medicine – 10th Edition