Gastrointestinal bleeding

Gastrointestinal bleeding can be roughly divided into two clinical syndromes: upper gastrointestinal bleeding and lower gastrointestinal bleeding. Upper gastrointestinal with a clean base, which is a common cause of upper gastrointestinal hemorrhage. image of small gastric ulcer with visible blood vessels, a potential warning sign for upper gastrointestinal bleeding Upper gastrointestinal bleeding is from a source between the pharynx and the ligament of Treitz. An upper source is characterised by hematemesis (vomiting up blood) and melena (tarry stool containing altered blood). About half of cases are due to peptic ulcer disease (gastric or duodenal ulcers). Lower gastrointestinal can potentially cause lower gastrointestinal bleeding Lower gastrointestinal bleeding is typically from the colon, rectum or anus. Common causes of lower gastrointestinal bleeding include hemorrhoids, cancer, angiodysplasia, ulcerative colitis, Crohn's disease, and aortoenteric fistula. It may be indicated by the passage of fresh red blood rectally, especially in the absence of bloody vomiting. Lower gastrointestinal bleeding could also lead to melena if the bleeding occurs in the small intestine or proximal colon. ==Signs and symptoms==

Gastrointestinal bleeding can range from small non-visible amounts, which are only detected by laboratory testing, to massive bleeding where bright red blood is passed and shock develops. Rapid bleeding may cause syncope. A number of foods and medications can turn the stool either red or black in the absence of bleeding. Bismuth found in many antacids may turn stools black as may activated charcoal. Blood from the vagina or urinary tract may also be confused with blood in the stool. ==Diagnosis==

test Diagnosis is often based on direct observation of blood in the stool or vomit. Although fecal occult blood testing has been used in an emergency setting, this use is not recommended as the test has only been validated for colon cancer screening. Differentiating between upper and lower bleeding in some cases can be difficult. The severity of an upper GI bleed can be judged based on the Blatchford score but if positive is useful for ruling one in. Clots in the stool indicate a lower GI source while melana stools an upper one. Nuclear scintigraphy is a sensitive test for detecting occult gastrointestinal bleeding when direct imaging with upper and lower endoscopies are negative. Direct angiography allows for embolization of a bleeding source, but requires a bleeding rate faster than 1mL/minute. ==Prevention==

In patients with significant varices or cirrhosis nonselective β-blockers reduce the risk of future bleeding. Testing for and treating those who are positive for H. pylori is recommended. ==Treatment==

at risk for bleeding The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood. Oral and intravenous formulations may be equivalent; however, the evidence to support this is suboptimal. In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance. Somatostatin and octreotide, while recommended for varicial bleeding, have not been found to be of general use for non variceal bleeds. Variceal bleeding For initial fluid replacement, colloids or albumin is preferred in people with cirrhosis. It is the only medication that has been shown to reduce mortality in acute variceal bleeding. and may decrease mortality. No trials of vitamin K have been conducted. Blood products The evidence for benefit of blood transfusions in GI bleed is poor with some evidence finding harm. A massive transfusion protocol may be used, but there is a lack of evidence for this indication. A number of endoscopic treatments may be used, including: epinephrine injection, band ligation, sclerotherapy, and fibrin glue depending on what is found. Early endoscopy decreases hospital and the amount of blood transfusions needed. Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found. It is also recommended that people with high risk signs are kept in hospital for at least 72 hours. Surgery, while rarely used to treat upper GI bleeds, is still commonly used to manage lower GI bleeds by cutting out the part of the intestines that is causing the problem. Angiographic embolization may be used for both upper and lower GI bleeds. Transjugular intrahepatic portosystemic shunting (TIPS) may also be considered. ==Prognosis==

Death in those with a GI bleed is more commonly due to other illnesses (some of which may have contributed to the bleed, such as cancer or cirrhosis) than the bleeding itself. Despite treatment, re-bleeding occurs in about 7–16% of those with upper GI bleeding. In those with esophageal varices, bleeding occurs in about 5–15% a year and if they have bled once, there is a higher risk of further bleeding within six weeks. Testing and treating H. pylori if found can prevent re-bleeding in those with peptic ulcers. The benefits versus risks of restarting blood thinners such as aspirin or warfarin and anti-inflammatories such as NSAIDs need to be carefully considered. If aspirin is needed for cardiovascular disease prevention, it is reasonable to restart it within seven days in combination with a PPI for those with nonvariceal upper GI bleeding. ==Epidemiology==

Gastrointestinal bleeding from the upper tract occurs in 50 to 150 per 100,000 adults per year. It is more common than lower gastrointestinal bleeding which is estimated to occur at the rate of 20 to 30 per 100,000 per year. Risk of bleeding is more common in males and increases with age. ==References==