Gastrointestinal bleeding

Gastrointestinal bleeding can develop at any level from the oral cavity to the anus and may be obvious or hidden. There are many possible causes that divide bleeding from bleeding from the upper (above the connection of the Threitz) and the lower gastrointestinal tract.

[1], [2], [3], [4]

What causes gastrointestinal bleeding?

Bleeding of any etiology is more likely and potentially more dangerous in patients with chronic liver disease or hereditary coagulation disorders, as well as in patients taking potentially dangerous drugs. Drugs that can cause gastrointestinal bleeding include anticoagulants (heparin, warfarin) that affect platelet function (eg, aspirin, certain non-steroidal anti-inflammatory drugs, clopidogrel, selective serotonin receptor inhibitors) and affect the protective function of the mucosa (eg, nonsteroidal anti-inflammatory drugs).

Common causes of gastrointestinal bleeding

Upper GIT

• Duodenal ulcer (20-30%)
• Erodes of the stomach or duodenum (20-30%)
• Varicose veins of the esophagus (15-20%)
• Gastric ulcer (10-20%)
• Mallory-Weiss Syndrome (5-10%)
• Erosive esophagitis (5-10%)
• Diaphragmatic hernia
• Angioma (5-10%)
• Arteriovenous malformations (<5%)

Lower GIT

• Anal fissures
• Angiodysplasia (vascular ectasia)
• Colitis: radiation, ischemic
• Colon cancer
• Polyposis of large intestine
• Diverticular disease (diverticulosis)
• Inflammatory bowel diseases: ulcerative proctitis / colitis, Crohn's disease, infectious colitis

Diseases of the small intestine (rarely)

• Angiomas
• Arteriovenous malformations
• Meckel's diverticulum
• Tumors

[5], [6], [7], [8]

Symptoms of gastrointestinal bleeding

Symptoms of gastrointestinal bleeding depend on the location of the source and the degree of bleeding.

Hematomesis a vomiting of fresh blood and indicates bleeding from the upper gastrointestinal tract, usually from an arterial source or varicose veins. Vomiting of the "coffee grounds" type indicates a stopped or retarded bleeding and is associated with the conversion of hemoglobin to hydrochloric acid hematin having a brown color under the influence of hydrochloric acid.

The bloody stool is a discharge of "dirty" blood from the rectum and usually indicates bleeding from the lower gastrointestinal tract, but it can also be a consequence of massive bleeding from the upper gastrointestinal tract with rapid transit of blood through the intestine.

Melena is a black, tarry stool and definitely indicates bleeding from the upper gastrointestinal tract, but the source of bleeding may also be located in the thin or right half of the colon. Approximately 100-200 ml of blood from the upper gastrointestinal tract causes melena, which can persist for several days after bleeding. Black stools that do not contain occult blood may be the result of taking iron or bismuth preparations or being able to blacken the contents of the gut of food and should be differentiated with melena.

Chronic latent bleeding can develop in any part of the gastrointestinal tract and is revealed by chemical study of the stool.

Severe bleeding can occur in patients with symptoms of shock (eg, tachycardia, tachypnea, pallor, sweating, oliguria, confusion). Patients with concomitant ischemic heart disease may develop angina or myocardial infarction due to hypoperfusion.

Patients with less severe bleeding can only experience moderate tachycardia (HR> 100). Orthostatic changes in the pulse (an increase of> 10 beats / min) or blood pressure (a decrease in pressure by 10 mm Hg) often develop after an acute loss of 2 units of blood. However, the measurement of orthostatic indices is impractical in patients with severe bleeding (possibly the cause of fainting) and is unreliable as a method of determining intravascular volume in patients with moderate bleeding, especially elderly patients.

Patients with chronic bleeding may have symptoms and signs of anemia (eg, weakness, mild fatigue, paleness, chest pain, dizziness). Gastrointestinal bleeding can accelerate the development of hepatic encephalopathy or hepatorenal syndrome (secondary renal failure in liver failure).

Diagnosis of gastrointestinal bleeding

Stabilization of the patient's state by intravenous transfusion of fluids, blood, and other therapy is necessary before and during the diagnosis. In addition to anamnesis and physical examination, a laboratory and instrumental examination is necessary.

[9], [10], [11], [12], [13], [14], [15]

Anamnesis

Anamnesis allows diagnosis in about 50% of patients, but requires confirmation by research. Pain in the epigastric region, which decreases after ingestion or antacids, suggests a peptic ulcer. However, in many patients with bleeding ulcers, there is no indication of pain syndrome in the anamnesis. Weight loss and anorexia suggest a GI tract. Cirrhosis of the liver or chronic hepatitis in an anamnesis is associated with varicose veins of the esophagus. Dysphagia involves esophageal cancer or stricture. Nausea and vomiting before the onset of bleeding suggests Mallory-Weiss syndrome, although approximately 50% of patients with Mallory-Weiss syndrome have no history of these symptoms.

Bleeding in the anamnesis (eg, purpura, ecchymosis, hematuria) may indicate hemorrhagic diathesis (eg, hemophilia, hepatic insufficiency). Bloody diarrhea, fever and abdominal pain suggest inflammatory bowel disease (ulcerative colitis, Crohn's disease) or infectious colitis (eg, Shigella, Salmonella, Campylobacter, amoebiasis). Bloody stools suggest diverticulosis or angiodysplasia. Fresh blood only on toilet paper or on the surface of a decorated stool suggests internal hemorrhoids, while blood mixed with a stool indicates a more proximal source of bleeding.

Analysis of information about the use of medications can establish the use of drugs that break the protective barrier and damage the gastric mucosa (eg, aspirin, nonsteroidal anti-inflammatory drugs, alcohol).

[16], [17]

Physical examination

Blood in the nasal cavity or flowing down to the pharynx suggests a source located in the nasopharynx. Vascular asterisks, hepatosplenomegaly or ascites are associated with chronic liver diseases and, consequently, the source can be varicose veins of the esophagus. Arteriovenous malformations, especially mucous membranes, suggest hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber Syndrome). Teleangiectasia of the nail bed and gastrointestinal bleeding may indicate systemic scleroderma or a mixed disease of connective tissue.

Finger rectal examination is necessary for assessing the color of the stool, revealing voluminous rectum formations, cracks and hemorrhoids. The study of the stool for concealed blood completes the examination. Hidden blood in the stool can be the first sign of colon cancer or polyposis, especially in patients older than 45 years.

Study

Patients with a positive result of the analysis for latent blood in the feces need to perform a general blood test. Bleeding also requires the study of hemocoagulation ( platelet count, prothrombin time, activated partial thromboplastin time ) and hepatic functional tests ( bilirubin, alkaline phosphatase, albumin, ACT, ALT ). If there are signs of continued bleeding, you need to determine the blood group, the Rh factor. In patients with severe bleeding, hemoglobin and hematocrit should be determined every 6 hours. In addition, the necessary set of diagnostic tests should be performed.

Nasogastric sensing, aspiration of contents and gastric lavage should be performed in all patients with suspected bleeding from the upper gastrointestinal tract (eg, hematomesis, vomiting "coffee grounds", melena, massive rectal bleeding). Aspiration of blood from the stomach indicates active bleeding from the upper gastrointestinal tract, but approximately 10% of patients with bleeding from the upper gastrointestinal tract may not receive blood aspirated by the nasogastric tube. Content like "coffee grounds" indicates a slow or stopped bleeding. If the signs indicating a bleeding are not present and the contents with an admixture of bile, the nasogastric tube is removed; The probe can be left in the stomach to monitor the ongoing bleeding or its recurrence.

When bleeding from the upper digestive tract should be performed endoscopy with examination of the esophagus, stomach and duodenum. Because endoscopy can be both diagnostic and therapeutic, the study should be performed quickly with significant bleeding, but may be delayed by 24 hours if the bleeding has stopped or is slight. X-ray examination with barium of the upper gastrointestinal tract has no diagnostic value in acute bleeding. Angiography is of limited importance in the diagnosis of bleeding from the upper gastrointestinal tract (mainly in the diagnosis of bleeding in hepatobiliary fistulas), although it allows in certain cases to perform certain therapeutic manipulations (eg, embolization, introduction of vasoconstrictors).

Sigmoscopy with a flexible endoscope and a rigid anoscope can be performed for all patients with acute symptoms indicating hemorrhoidal bleeding. All other patients with a bloody stool need to perform a colonoscopy, which can be done, according to indications, after usual training, in the absence of continuing bleeding. In such patients, rapid preparation of the intestine (5-10 L of a solution of polyethylene glycol through a nasogastric tube or orally for 3-4 hours) often allows an adequate examination. If the source is not found during colonoscopy, and intensive bleeding continues (> 0.5-1 ml / min), the source can be detected by angiography. Some angiologists initially perform a radionuclide scan for preliminary evaluation of the source, but the effectiveness of this approach is unproven.

The diagnosis of latent bleeding may be difficult, since a positive result of an analysis of occult blood may be a consequence of bleeding from any part of the gastrointestinal tract. Endoscopy is the most informative method in the presence of symptoms that determine the need for priority examination of the upper or lower gastrointestinal tract. If it is impossible to perform a colonoscopy in the diagnosis of bleeding from the lower GI tract, an irrigoscopy with double contrast and sigmoidoscopy can be used. If the results of endoscopy of the upper gastrointestinal tract and colonoscopy are negative, and hidden blood remains in the stool, one should study the passage through the small intestine, perform a small intestine endoscopy (enteroscopy), scan with radioisotope colloid or "labeled" radioisotope "label" erythrocytes using technetium, and perform angiuraphy.

Treatment of gastrointestinal bleeding

Hematomesis, bloody stools or melena should be regarded as a critical condition. All patients with severe bleeding from the gastrointestinal tract are advised to consult a gastroenterologist and surgeon and to be admitted to the hospital. General treatment is aimed at maintaining the patency of the airways and restoring the volume of circulating blood. Hemostatic therapy and other treatment of gastrointestinal bleeding depend on the cause of bleeding.

Airways

An important cause of complications and mortality in patients with active bleeding from the upper gastrointestinal tract is aspiration of blood with subsequent respiratory disorders. For the prevention of aspiration, patients with a disturbed pharyngeal reflex, confused or lacking consciousness, are shown to have endotracheal intubation, especially if endoscopy is necessary or the Sengstacken-Blackmore probe is inserted.

[18], [19], [20], [21],

BCC Recovery

Intravenous fluids are indicated for all patients with hypovolemia or hemorrhagic shock: adults are transfused intravenously from 500-1000 ml to a maximum of 2 l to fully compensate for signs of hypovolemia (for children 20 ml / kg with a possible repeated transfusion). Patients requiring further intensive care, need a transfusion of erythrocyte mass. Transfusions continue until the intravascular volume is restored and, if necessary, blood replacement therapy is performed. Transfusions can be stopped in case of stable hematocrit (30) and if the patient does not require symptomatic treatment. Patients with chronic bleeding usually do not receive blood transfusion if the hematocrit is not less than 21 or if symptoms of dyspnea or coronary ischemia are observed.

A constant control of the number of platelets is necessary; the need for transfusion of platelets can occur with severe bleeding. Patients taking antiplatelet drugs (eg, clopidogrel, aspirin) have platelet dysfunction, often leading to increased bleeding. Transfusion of platelets is indicated in case of severe continuing bleeding in patients taking such drugs, although residual circulating blood (especially clopidogrel) can inactivate transfused platelets.

[22], [23], [24], [25], [26]

Hemostasis

Gastrointestinal bleeding spontaneously stops in approximately 80% of patients. The remaining patients require certain types of interventions. Specific treatment of gastrointestinal bleeding depends on the source of bleeding. Early intervention to stop bleeding is aimed at reducing mortality, especially in elderly patients.

Continuing bleeding in the peptic ulcer or recurrence of bleeding is an indication for endoscopic coagulation (bipolar electrocoagulation, injection sclerotherapy, diathermy, or laser). Unscratching vessels, visualized in the crater of an ulcer, are also subject to treatment. In the case of ineffectiveness of endoscopic hemostasis, surgical intervention is aimed at stitching the source of bleeding. In such situations, some surgeons perform operations aimed at reducing acidity.

Active bleeding from varicose veins requires endoscopic suture, injective sclerotherapy, or a transureular intrahepatic portosystemic shunting (TIPS).

In case of severe, continuing bleeding from the lower gastrointestinal tract, bleeding from diverticula or angiomas, a colonoscopic electric cauter, coagulation with diathermy, or epinephrine solution can be used. Polyps can be removed by a loop or cauterization. If these methods are ineffective or unachievable, angiography with embolization or administration of vasopressin can be effective. However, in view of the fact that collateral blood flow in the gut is limited, angiographic methods have a significant risk of developing bowel ischemia or infarction. The administration of vasopressin is effective in approximately 80% of cases, but in 50% of patients the bleeding recurs. In addition, there is a risk of hypertension and coronary ischemia. Surgical intervention can be used in patients with ongoing bleeding (needing transfusion more than 4 doses of blood / 24 hours), but localization of the source of bleeding is very important. Selective hemicolectomy (without preoperative identification of the source of bleeding) entails a much higher risk of mortality than targeted segmental resection. Therefore, the studies should be so fast as possible so that extensive surgical intervention can be avoided.

Acute or chronic gastrointestinal bleeding with internal hemorrhoids in most cases stops spontaneously. Patients with unstable bleeding need an anoscopy with ligation of the nodes with latex rings, injection therapy, coagulation or hemorrhoidectomy.