Gastrointestinal bleeding: Difference between revisions
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{{Gastrointestinal bleeding}} | {{Gastrointestinal bleeding}} | ||
{{CMG}} ; {{AE}} {{ADG}}<br> | {{CMG}} ; {{AE}} {{ADG}}<br> | ||
{{SK}} Blood loss from GI tract; bloody stool; blood in | {{SK}} Blood loss from GI tract; bloody stool; blood in feces; PR bleeding; gastrointestinal hemorrhage; gastrointestinal hemorrhage; GI bleeding; bright red blood per rectum; BRBPR. | ||
==Overview== | ==Overview== | ||
Gastrointestinal bleeding is defined as bleeding from any part of GI tract starting from mouth to anus. It can also be called as gastrointestinal hemorrhage. Based on the origin of bleeding it can be classified into upper gastrointestinal bleeding and lower gastrointestinal bleeding. Upper gastrointestinal bleeding (UGIB) is defined as bleeding from the gastrointestinal tract that originates proximal to the ligament of Treitz. Lower gastrointestinal bleeding is defined as blood loss originating distal to the ligament of Treitz. The most common causes of UGIB are peptic ulcer disease and esophageal varice while diverticulosis is the most commonly responsible for lower gastrointestinal bleeding. Clinical presentation includes overt bleeding from the gastrointestinal tract, rapid or slow, either manifested by hematemesis of fresh (blood-streaked to frankly bloody), old ('coffee ground') vomitus, melena and or as frank blood per rectum. | Gastrointestinal (GI) bleeding is defined as [[bleeding]] from any part of [[GI tract]] starting from [[mouth]] to [[anus]]. It can also be called as [[Gastrointestinal bleeding|gastrointestinal hemorrhage]]. Based on the origin of [[bleeding]] it can be classified into upper gastrointestinal bleeding and lower gastrointestinal bleeding. Upper gastrointestinal bleeding (UGIB) is defined as bleeding from the gastrointestinal tract that originates [[proximal]] to the [[ligament of Treitz]]. Lower gastrointestinal bleeding is defined as blood loss originating [[distal]] to the [[ligament of Treitz]]. The most common causes of UGIB are [[peptic ulcer disease]] and [[esophageal varice]] while [[diverticulosis]] is the most commonly responsible for lower gastrointestinal bleeding. Clinical presentation includes overt bleeding from the gastrointestinal tract, rapid or slow, either manifested by [[hematemesis]] of fresh (blood-streaked to frankly bloody), old ('coffee ground') vomitus, [[melena]] and or as frank blood per rectum. | ||
*'''Haematemesis''': | |||
*'''Coffee ground emesis''': | Common risk factors in the development of GI bleeding include advancing age, previous history of [[gastrointestinal bleed]], chronic [[constipation]], [[hematologic disorders]], anticoagulants medications, [[non-steroidal anti-inflammatory drugs]]. It is essential to distinguish between lower gastrointestinal bleeding and brisk upper gastrointestinal bleeding as they can present with similar symptoms. Patients with severe bleeding or hemodynamic disturbance require hospitalization and urgent investigation. Treatment depends on the cause and the severity of the bleeding. | ||
*'''Melaena''': | |||
==Types of bleeding== | |||
Bleeding from the gastrointestinal tract can be of the following types: | |||
*'''Haematemesis''': [[Vomiting]] fresh red blood. | |||
*'''Coffee ground emesis''': Vomiting of altered black blood. | |||
*'''Melaena''': Passage of black tarry stools. | |||
*'''Haemochezia''': Passage of red blood per rectum (usually due to bleeding from the lower gastrointestinal tract but occasionally can be due to massive upper gastrointestinal bleeding). | *'''Haemochezia''': Passage of red blood per rectum (usually due to bleeding from the lower gastrointestinal tract but occasionally can be due to massive upper gastrointestinal bleeding). | ||
*'''Rebleeding''': Defined as fresh haematemesis and/or melaena associated with the development of shock (pulse greater than 100 beats/min, systolic pressure less than 100 mm Hg), a fall in CVP greater than 5 mm Hg, or a reduction in haemoglobin concentration greater than 20 g/l over 24 hours. Rebleeding should always be confirmed by endoscopy. | *'''Rebleeding''': Defined as fresh [[haematemesis]] and/or [[melaena]] associated with the development of [[shock]] (pulse greater than 100 beats/min, systolic pressure less than 100 mm Hg), a fall in [[CVP]] greater than 5 mm Hg, or a reduction in [[haemoglobin]] concentration greater than 20 g/l over 24 hours. Rebleeding should always be confirmed by endoscopy. | ||
==Causes== | ==Causes== | ||
{| class="wikitable" | {| class="wikitable" | ||
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*[[Esophageal cancer|Esophageal tumors]] | *[[Esophageal cancer|Esophageal tumors]] | ||
*[[Esophagitis]] | *[[Esophagitis]] | ||
*Gastric erosions/gastropathy | *Gastric erosions/[[gastropathy]] | ||
*Dieulafoy lesions | *Dieulafoy lesions | ||
*[[Gastric antral vascular ectasia]] | *[[Gastric antral vascular ectasia]] | ||
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| | | | ||
* [[Diverticulosis]] | * [[Diverticulosis]] | ||
* Vascular ectasias | * [[Angiodysplasia|Vascular ectasias]] | ||
* Ischemic colitis | * [[Ischemic colitis]] | ||
* Colorectal malignancy | * [[Colorectal cancer|Colorectal malignancy]] | ||
* Hemorrhoids | * [[Hemorrhoids]] | ||
* Anal fissures | * [[Anal fissures]] | ||
* Crohn's disease | * [[Crohn's disease]] | ||
* Ulcerative colitis | * [[Ulcerative colitis]] | ||
* Infectious colitis | * [[Infectious colitis]] | ||
* [[Colonic polyps]] | |||
* Colonic polyps | * [[Radiation proctitis]] | ||
* Radiation proctitis | * [[Rectal varices]] | ||
* Rectal varices | |||
* Stercoral ulceration | * Stercoral ulceration | ||
* Meckel diverticulum | * [[Meckel diverticulum]] | ||
* | * [[Intussusception]] | ||
* Henoch-Schönlein purpura (HSP) | * [[Henoch-Schönlein purpura]] (HSP) | ||
|} | |} | ||
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* Gastric ulcer- [[melena]] and [[hematemesis]] | * Gastric ulcer- [[melena]] and [[hematemesis]] | ||
* Duodenal ulcer- [[melena]] and [[hematochezia]] | * Duodenal ulcer- [[melena]] and [[hematochezia]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present if perforated | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present if perforated | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present if perforated | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |N | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" | | | style="padding: 5px 5px; background: #F5F5F5;" align="left" | | ||
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| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present in chronic gastritis | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
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| style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |− | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present in perforated diverticulitis | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
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| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present in fulminant colitis | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | ± | ||
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| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present in liver failure leading to [[varices]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
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| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present in cirrhotic patients | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
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| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Mesenteric ischemia]] | | style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Mesenteric ischemia]] | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Periumbilical | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Periumbilical | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |Present if bowel becomes gangrenous | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
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| style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | | style="padding: 5px 5px; background: #F5F5F5;" align="center" |<nowiki>+</nowiki> | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | + | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present if bowel becomes gangrenous | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | Present if bowel becomes gangrenous | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | | style="padding: 5px 5px; background: #F5F5F5;" align="center" | − | ||
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive to absent | | style="padding: 5px 5px; background: #F5F5F5;" align="left" |Hyperactive to absent | ||
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'''[[RUQ]]'''= Right upper quadrant of the abdomen, '''LUQ'''= Left upper quadrant, '''LLQ'''= Left lower quadrant, '''RLQ'''= Right lower quadrant, '''LFT'''= Liver function test, SIRS= [[Systemic inflammatory response syndrome]], '''[[ERCP]]'''= [[Endoscopic retrograde cholangiopancreatography]], '''IV'''= Intravenous, '''N'''= Normal, '''AMA'''= Anti mitochondrial antibodies, '''[[LDH]]'''= [[Lactate dehydrogenase]], '''GI'''= Gastrointestinal, '''CXR'''= Chest X ray, '''IgA'''= [[Immunoglobulin A]], '''IgG'''= [[Immunoglobulin G]], '''IgM'''= [[Immunoglobulin M]], '''CT'''= [[Computed tomography]], '''[[PMN]]'''= Polymorphonuclear cells, '''[[ESR]]'''= [[Erythrocyte sedimentation rate]], '''[[CRP]]'''= [[C-reactive protein]], TS= [[Transferrin saturation]], SF= Serum [[Ferritin]], SMA= [[Superior mesenteric artery]], SMV= [[Superior mesenteric vein]], ECG= [[Electrocardiogram]]</span> | '''[[RUQ]]'''= Right upper quadrant of the abdomen, '''LUQ'''= Left upper quadrant, '''LLQ'''= Left lower quadrant, '''RLQ'''= Right lower quadrant, '''LFT'''= Liver function test, SIRS= [[Systemic inflammatory response syndrome]], '''[[ERCP]]'''= [[Endoscopic retrograde cholangiopancreatography]], '''IV'''= Intravenous, '''N'''= Normal, '''AMA'''= Anti mitochondrial antibodies, '''[[LDH]]'''= [[Lactate dehydrogenase]], '''GI'''= Gastrointestinal, '''CXR'''= Chest X ray, '''IgA'''= [[Immunoglobulin A]], '''IgG'''= [[Immunoglobulin G]], '''IgM'''= [[Immunoglobulin M]], '''CT'''= [[Computed tomography]], '''[[PMN]]'''= Polymorphonuclear cells, '''[[ESR]]'''= [[Erythrocyte sedimentation rate]], '''[[CRP]]'''= [[C-reactive protein]], TS= [[Transferrin saturation]], SF= Serum [[Ferritin]], SMA= [[Superior mesenteric artery]], SMV= [[Superior mesenteric vein]], ECG= [[Electrocardiogram]]</span> | ||
== | ==Symptomatic approach to the differential of Upper gastrointestinal bleeding== | ||
== | <small> | ||
{{ | {{familytree/start |summary=Sample 1}} | ||
{{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | A01=Gastrointestinal Bleeding}} | |||
{{familytree | | | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | C01 | | | | | | | | C02 | | | | | | | | | | | | | |C01=Blood in [[Vomiting]]|C02=Black tarry stools|C03=Blood in stools}} | |||
{{familytree | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | |`|-|-|-| D01 |-|-|-|'| | | | | | | | | | | | | | | | D01=[[Abdominal pain]] |D02=[[Abdominal pain]]}} | |||
{{familytree | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | E01 | | | | | | | | | | | | | E02 | | | | | | | | | | | | | | | |E01='''Yes'''|E02='''No'''|}} | |||
{{familytree | | | | | | | |!| | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | F01 | | | | | | | | | | | | | F02 | | | | | | | | | | | | | | | | | |F01=[[Weight loss]]|F02=[[Dysphagia]]}} | |||
{{familytree | | | |,|-|-|-|^|-|-|-|-|-|.| | | | |,|-|-|-|^|-|-|-|-|.| | | | | | | | | |}} | |||
{{familytree | | | G01 | | | | | | | | G02 | | | G03 | | | | | | | G04 | | | | | | | | | |G01='''Yes'''|G02='''No'''|G03='''No'''|G04='''Yes'''}} | |||
{{familytree | | | |!| | | | | | | | | |!| | | | |!| | | | | | | | |!| | | | | | | | | |}} | |||
{{familytree | | | |!| | | | | | | | | |!| | | | H03 | | | | | | | H04 | | | | | | | | | |H03=[[Mallory-Weiss syndrome]]<br>[[Boerhaave syndrome]]|H04=[[Weight loss]]}} | |||
{{familytree | | | |!| | | | | | | | | H02 | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | |H02=[[Dyspepsia]]}} | |||
{{familytree | | | A01 | | | | |,|-|-|-|^|-|-|-|.| | | | | I03 | | | | | | I04 | | | | | |A01='''[[Gastric cancer]]'''<br>'''[[Gastric ulcer]]'''|I03=Yes|I04=No|}} | |||
{{familytree | | | | | | | | | I01 | | | | | | I02 | | | | |!| | | | | | | |!| | | | | | |I01=Yes|I02=No}} | |||
{{familytree | | | | | | | | | |!| | | | | | | |!| | | | | J03 | | | | | | J04 | | | | | |J03=[[Esophageal carcinoma]]|J04=Immune status}} | |||
{{familytree | | | | | | | | | J01 | | | | | | J02 | | | | | | | | |,|-|-|-|^|-|-|.| | | | |J01=[[Duodenal ulcer]]|J02=[[Varices]]}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | K01 | | | | | K02 | | |K01=Immunocomprimised|K02=Immunocompetent|}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | |!| | | |}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | L01 | | | | | L02 | | L01=Infectious [[esophagitis]]|L02=Pill induced [[esophagitis]]}} | |||
{{familytree/end}} | |||
</small> | |||
==Symptomatic approach to differential of lower gastrointestinal bleeding== | |||
<small> | |||
<div style="width: 55%;"> | |||
{{familytree/start |summa|ry=Sample 1}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | A01=Blood in stools}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | M01 |M01=[[Abdominal pain]] }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | |,|-|-|-|-|^|-|-|-|.| }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | N01 | | | | | | | N02 | | |N01=Yes|N02=No}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |!| | | |}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | O01 | | | | | | | O02 | |O01=[[Fever]]|O02=Rectal pain}} | |||
{{familytree | | | | | | | | | | | | | | | |,|-|-|-|-|-|-|-|-|-|-|-|-|^|-|-|-|-|.| | | |!| | }} | |||
{{familytree | | | | | | | | | | | | | | | P01 | | | | | | | | | | | | | | | | P02 | | |!|P01=Yes|P02=No}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | |!| | }} | |||
{{familytree | | | | | | | | | | | | | | | Q01 | | | | | | | | | | | | | | | | Q02 | | |`|-|-|.|Q01=H/O of [[constipation]]|Q02=H/O of [[constipation]]}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |,|-|-|-|^|-|-|-|.| | |!||}} | |||
{{familytree | | | | | | | | | | |,|-|-|-|-|^|-|-|-|.| | | | | | | | | B01 | | | | | | B02 | |!|B01=No|B02=Yes|}} | |||
{{familytree | | | | | | | | | | R01 | | | | | | | R02 | | | | | | | | |!| | | | | | | |!| | |!| R01=No|R02=Yes}} | |||
{{familytree | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | C01 | | | | | | C02 | |!|C01=[[Weight loss]]|C02=[[Diverticulosis]]}} | |||
{{familytree | | | | | | | | | | S01 | | | | | | | S02 | | | | |,|-|-|-|^|-|-|-|.| | | | | | |!|S01=Hemodynamic status|S02=[[Diverticulitis]]| }} | |||
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | | | D01 | | | | | | D02 | | | | | |!|D01=No|D02=Yes}} | |||
{{familytree | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | |!| | | | | | | |!| | | | | | |!|}} | |||
{{familytree | | | | | | T01 | | | | | | T02 | | | | | | | | | E01 | | | | | | E02 | | | | | |!|T01=Stable|T02=Unstable|E01=[[Polyps]]|E02=[[Colon cancer]]}} | |||
{{familytree | | | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | |!|}} | |||
{{familytree | | | | | | |!| | | | | | | A01 | | | | | | | | | | | | | | | | | | | | |,|-|-|-|'|A01=[[Ischemic colitis]]}} | |||
{{familytree | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | |B01=[[Stool culture]]}} | |||
{{familytree | | |,|-|-|-|^|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | |,|-|-|-|^|-|-|-|-|.|}} | |||
{{familytree | | |!| | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |!| |}} | |||
{{familytree | | X03 | | | | | | | X04 | | | | | | | | | | | | | | | | | | | X01 | | | | | | | X02 |X01=No|X02=Yes|X03=Positive|X04=Negative}} | |||
{{familytree | | |!| | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |!| | | | | | | | |!| |}} | |||
{{familytree | | U03 | | | | | | | U04 | | | | | | | | | | | | | | | | | | | U01 | | | | | | | U02 |U01=Weight Loss|U02=[[Anal fissure]]<br> External [[Hemorrhoids]]|U03=[[Infectious colitis]]|U04=[[Inflammatory bowel disease]]}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |,|-|-|-|-|^|-|-|-|-|.| |}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | C03 | | | | | | | | C04 |C03=Yes|C04=No|}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | |!| | }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | D01 | | | | | | | | D02 |D01=Rectal cancer<br>[[Colon cancer]]|D02=[[Angiodysplasia]]<br>Polyps }} | |||
{{familytree/end}} | |||
</div> | |||
</small> | |||
[[Category:Surgery]] | [[Category:Surgery]] | ||
[[Category:Gastroenterology]] | [[Category:Gastroenterology]] |
Latest revision as of 02:25, 23 December 2017
Gastrointestinal bleeding Main page |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Synonyms and keywords: Blood loss from GI tract; bloody stool; blood in feces; PR bleeding; gastrointestinal hemorrhage; gastrointestinal hemorrhage; GI bleeding; bright red blood per rectum; BRBPR.
Overview
Gastrointestinal (GI) bleeding is defined as bleeding from any part of GI tract starting from mouth to anus. It can also be called as gastrointestinal hemorrhage. Based on the origin of bleeding it can be classified into upper gastrointestinal bleeding and lower gastrointestinal bleeding. Upper gastrointestinal bleeding (UGIB) is defined as bleeding from the gastrointestinal tract that originates proximal to the ligament of Treitz. Lower gastrointestinal bleeding is defined as blood loss originating distal to the ligament of Treitz. The most common causes of UGIB are peptic ulcer disease and esophageal varice while diverticulosis is the most commonly responsible for lower gastrointestinal bleeding. Clinical presentation includes overt bleeding from the gastrointestinal tract, rapid or slow, either manifested by hematemesis of fresh (blood-streaked to frankly bloody), old ('coffee ground') vomitus, melena and or as frank blood per rectum.
Common risk factors in the development of GI bleeding include advancing age, previous history of gastrointestinal bleed, chronic constipation, hematologic disorders, anticoagulants medications, non-steroidal anti-inflammatory drugs. It is essential to distinguish between lower gastrointestinal bleeding and brisk upper gastrointestinal bleeding as they can present with similar symptoms. Patients with severe bleeding or hemodynamic disturbance require hospitalization and urgent investigation. Treatment depends on the cause and the severity of the bleeding.
Types of bleeding
Bleeding from the gastrointestinal tract can be of the following types:
- Haematemesis: Vomiting fresh red blood.
- Coffee ground emesis: Vomiting of altered black blood.
- Melaena: Passage of black tarry stools.
- Haemochezia: Passage of red blood per rectum (usually due to bleeding from the lower gastrointestinal tract but occasionally can be due to massive upper gastrointestinal bleeding).
- Rebleeding: Defined as fresh haematemesis and/or melaena associated with the development of shock (pulse greater than 100 beats/min, systolic pressure less than 100 mm Hg), a fall in CVP greater than 5 mm Hg, or a reduction in haemoglobin concentration greater than 20 g/l over 24 hours. Rebleeding should always be confirmed by endoscopy.
Causes
Gastrointestinal bleeding | Lethal causes | Common causes | Less common causes |
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Upper gastrointestinal bleeding |
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Lower gastrointestinal bleeding |
Classification
The following flow chart elobarates the classification of gastrointestinal bleeding:
Gastrointestinal bleeding | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Upper GI bleeding | Lower GI bleeding | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Based on blood loss | Based on severity of blood loss | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Overt | Occult | Obscure | Severe | Moderate | Occult | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Hematemesis Coffee-ground emesis Melena | Microscopic hemorrhage Heme-occult positive stools | Source is not identified | Hematochezia | Hematochezia | Microscopic hemorrhage Heme-occult positive stools | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Differentiating Gastrointestinal Bleeding from other Diseases
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Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram
Symptomatic approach to the differential of Upper gastrointestinal bleeding
Gastrointestinal Bleeding | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Blood in Vomiting | Black tarry stools | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Abdominal pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Weight loss | Dysphagia | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Mallory-Weiss syndrome Boerhaave syndrome | Weight loss | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Dyspepsia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Gastric cancer Gastric ulcer | Yes | No | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Esophageal carcinoma | Immune status | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Duodenal ulcer | Varices | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Immunocomprimised | Immunocompetent | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Infectious esophagitis | Pill induced esophagitis | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Symptomatic approach to differential of lower gastrointestinal bleeding
Blood in stools | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Abdominal pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Fever | Rectal pain | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
H/O of constipation | H/O of constipation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Weight loss | Diverticulosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Hemodynamic status | Diverticulitis | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stable | Unstable | Polyps | Colon cancer | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ischemic colitis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stool culture | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Positive | Negative | No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Infectious colitis | Inflammatory bowel disease | Weight Loss | Anal fissure External Hemorrhoids | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Rectal cancer Colon cancer | Angiodysplasia Polyps | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||