Gastrointestinal Hemorrhage: Key Signs, Causes, and Treatments

Gastrointestinal hemorrhage refers to bleeding anywhere in the digestive tract, including the esophagus, stomach, small intestine, large intestine or colon, rectum, and anus. GI bleeding is a symptom rather than a disease and indicates an underlying ailment that needs to be diagnosed. The gastrointestinal hemorrhage causes blood loss, potentially leading to serious health complications. The causes of GI bleeding can range from minor, such as peptic ulcers or hemorrhoids, to severe, such as cancer or a tear in the wall of the gastrointestinal tract.

Types of Gastrointestinal Hemorrhage:

Gastrointestinal bleeding can be classified into:

1. Upper gastrointestinal bleeding means bleeding in the esophagus, stomach, or first section of the small intestine (duodenum).¹M. Feinman and E. R. Haut, “Upper Gastrointestinal Bleeding,” Surg. Clin. North Am., vol. 94, no. 1, pp. 43–53, Feb. 2014, doi: 10.1016/j.suc.2013.10.004.
2. Lower gastrointestinal bleeding means bleeding in the jejunum or ileum (lower parts of the small intestine) or large intestine, anus, and rectum. Symptoms of GI bleeding may include abdominal pain, blood in vomit, black or dark stools (called melena), weakness, dizziness, and a rapid heartbeat. If not treated promptly, GI bleeding can lead to serious health complications, such as anemia, shock, or death. The treatment for GI bleeding depends on the underlying cause and can range from medication to surgery.

What Conditions Can Cause Gastrointestinal Hemorrhage?

The causes are broadly classified based upon their location, i.e., whether bleeding occurs from upper GIT or lower GIT, and are further elaborated as below:

Causes of Upper GI bleed:

Ulcers in the stomach:

Peptic ulcers are usually caused by a Helicobacter pylori infection or irritation from nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin or ibuprofen² J. L. Goldstein and B. Cryer, “Gastrointestinal injury associated with NSAID use: A case study and review of risk factors and preventative strategies,” Drug. Healthc. Patient Saf., vol. 7, pp. 31–41, Jan. 2014, doi: 10.2147/DHPS.S71976.. ThePepticers are a common source of gastrointestinal bleeding. If you take blood thinners, you may be at a higher risk. Many people with ulcers have no symptoms.

Tears in your esophageal veins:

Esophageal varices are swollen veins that can form near the esophagus’s lower end. They are most common in people with liver disease, such as cirrhosis (liver scarring due to chronic liver disease).
Unless the veins begin to bleed, people with esophageal varices usually have no symptoms, but if they do, that could be potentially fatal.

Tears in your esophageal wall:

Tears in the esophageal lining frequently occur due to prolonged vomiting or coughing. Mallory-Weiss syndrome (partial tears in the esophageal wall due to repetitive retching) can result in significant bleeding. Although they can sometimes heal independently, this is not always the case. Some people may require treatment to stop bleeding and prevent profound blood loss³ F. Guo, J. Wang, K. Liu, Z. Zeng, and F. Luo, “Case Report Small-cell lung cancer with Mallory-Weiss syndrome as the prominent manifestation,” Int J Clin Exp Pathol, vol. 12, no. 7, pp. 2758–2762, 2019, Accessed: Feb. 09, 2023. [Online]. Available: www.ijcep.com/. Severe vomiting is a common cause of the disease.

Duodenitis and gastroenteritis:

Enteritis develops when the small intestine becomes inflamed, usually due to a bacterial or viral infection. Gastritis refers to stomach inflammation, whereas duodenitis refers to small intestine inflammation. Radiation therapy, certain medications, alcohol, or inflammatory bowel disease can all cause such inflammations, although they can also be caused by other factors such as excessive use of NSAIDs.
Enteritis caused by an infection can result in nausea, vomiting, diarrhea, cramps, and rectal bleeding.

Ingestion of a foreign body:

Any foreign body Ingestion can lead to injury to the oral cavity, esophagus, stomach, or small intestine, thus involving the whole upper GI tract and eventually leading to upper GI bleeding.

Tumors of the GI tract:

It is not that much common for GI tumors to bleed. However, any cancer along the GI tract can lead to severe upper GI hemorrhage and sometimes shock-like symptoms.

Angiodysplasia:

Angiodysplasia is a severe vascular lesion of the gastrointestinal tract characterized by swollen blood vessels that may begin to bleed. It can cause severe morbidity from bleeding.

Causes of Lower GI bleed:

Multiple reasons are reported, but the important ones are discussed below:

Hemorrhoids and anal fissures

Hemorrhoids are swollen veins in the anal canal that have the potential to rupture and might result in fresh GI bleeding. It may swell as a result of constipation and straining during bowel motions. Additionally, it may cause irritation, pain, and occasionally bleeding in the anus and lower rectum.

This ailment may resolve on its own or with only minor treatments. However, if the bleeding appears, a doctor may decide to perform a colonoscopy to look for other potentially serious causes⁴T. Adegboyega and D. Rivadeneira, “Lower GI Bleeding: An Update on Incidences and Causes,” Clin. Colon Rectal Surg., vol. 33, no. 1, pp. 28–34, 2020, doi: 10.1055/S-0039-1695035/ID/JR00961-59..

An anal fissure can also cause lower GI bleeding. It is a tear in the anal sphincter’s muscular ring that can cause itching, tearing, or bleeding. Constipation or firm stools are generally to blame⁵M. Feinman and E. R. Haut, “Lower Gastrointestinal Bleeding,” Surg. Clin. North Am., vol. 94, no. 1, pp. 55–63, Feb. 2014, doi: 10.1016/j.suc.2013.10.005..

Diverticulosis:

Diverticulosis is a chronic condition in which the colon wall protrudes at the location of vessels, causing the vessels to burst and bleed over time. The most prevalent cause of overt lower gastrointestinal bleeding in adults is colonic diverticular hemorrhage. In most circumstances, the bleeding will stop on its own. If the bleeding continues, endoscopic, radiologic, or surgical intervention may be necessary. A clinician may perform a colonoscopy to rule out other, more serious reasons for lower GI bleeding, including cancer.

Cancer of the colon:

Colorectal cancer starts in the colon or rectum. Lower gastrointestinal (GI) bleeding is a well-known sign of colorectal cancer (CRC). It is unknown whether acute GI bleeding is a signal for other GI malignancies.

Angiodysplasia:

This condition results in enlarged blood vessels in the gastrointestinal tract.

Colitis:

Colitis, which happens when your colon gets inflamed, is one of the most prevalent causes of lower GI bleeding.

Massive bleeding from inflammatory bowel disease (aka IBD, a group of diseases in which bowel walls get damaged due to the body’s inadequate immune response against its tissues) is uncommon. Ulcerative colitis (one form of IBD) causes bloody diarrhea and overt lower GI bleeding, while Crohn’s disease (another form of IBD) may present with occult GI bleeding.

Sign and Symptoms of Gastrointestinal Hemorrhage

GI bleeding symptoms can be either visible (overt) or hidden (occult)⁶A. D. Hopper and D. S. Sanders, “Upper GI bleeding requires prompt investigation,” Practitioner, vol. 255, no. 1742, pp. 15–20, Jul. 2011, Accessed: Feb. 09, 2023. [Online]. Available: https://go.gale.com/ps/i.do?p=AONE&sw=w&issn=00326518&v=2.1&it=r&id=GALE%7CA334170291&sid=googleScholar&linkaccess=fulltext.

Overt bleeding can manifest as:

• Vomiting blood (also called hematemesis), which may be crimson or dark brown in color and texture and resembles coffee grounds
• Black-colored stools (called melena)
• Fresh rectal bleeding, generally with the passage of stool

You may have the following symptoms if you have occult bleeding:

• Lightheadedness
• Having trouble breathing
• Paleness
• Shortness of breath
• Fainting
• Chest ache
• Pain in the abdomen

How will your doctor manage Gastrointestinal Hemorrhage?

The management of GIT bleeding depends on the underlying cause and severity. Treatment goals are generally to stop the bleeding, maintain hemodynamic stability, and prevent complications. Stabilizing the patient’s airways and administering IV fluids or transfusing blood are the first steps in managing severe cases.

Your doctor will take a medical history, including any previous bleeding history, perform a physical exam, and may request tests. Tests could include:

Endoscopy:

Endoscopy⁷L. Fisher et al., “The role of endoscopy in managing obscure GI bleeding,” Gastrointest. Endosc., vol. 72, no. 3, pp. 471–479, Sep. 2010, doi: 10.1016/J.GIE.2010.04.032. is the best approach to diagnose and treat the cause of upper GI bleeding and will be recommended if the bleeding has been severe. A fiber optic flexible tube with a video system is used in this examination to provide a direct view of the GI tract. If there is active bleeding, it can be halted by injecting medicines at the site.

Blood tests:

Your doctor will perform a complete blood count and coagulation monitoring such as total count of platelets, prothrombin time (PT), and partial thromboplastin time (PTT), as well as liver function tests such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and bilirubin and albumin, in certain patients with more significant bleeding.

Stool examinations:

If no gross blood is found, chemical testing of a stool specimen for occult blood completes the assessment.

Nasogastric Lavage:

A tube is inserted via your nose and into your stomach. This may aid in determining the source of your hemorrhage.

Colonoscopy:

All other patients with hematochezia (Rectal bleeding) should undergo a colonoscopy. In this technique, a tiny camera attached to the end of a long tube is pushed through your rectum to allow your doctor to observe your big intestine and rectum. If colonoscopy cannot identify the source and ongoing bleeding is rapid (>0.5 to 1 mL/min), angiography may help.

Capsule Endoscopy and Angiography

In this process, you ingest a vitamin-sized capsule containing a tiny camera. Although endoscopy is therapeutic and diagnostic, it should be performed immediately if there is substantial upper GI bleeding. Furthermore, endoscopy enables the visualization and biopsy of lesions and the management of bleeding.

Angiography aids in diagnosing upper gastrointestinal bleeding and allows for specific treatment approaches (e.g., embolization, vasoconstrictor infusion). Additionally, angiography is a minimally invasive procedure that can be performed rapidly in an emergency. In angiography, a contrast dye is injected into an artery, followed by X-rays to detect and treat bleeding arteries or other problems.

Flexible Sigmoidoscopy:

Your doctor will introduce an instrument with a light and camera source at its tip into your rectum to examine it and the last section of the large intestine that goes to your rectum (sigmoid colon). Additionally, flexible sigmoidoscopy allows for removing polyps and tissue samples for biopsy. For patients with hemorrhoidal bleeding symptoms, flexible sigmoidoscopy may be all that is needed in the short term.

Balloon-assisted Enteroscopy:

A specialized scope inspects regions of your small intestine that other endoscope examinations cannot reach. During this test, the source of the bleeding may be controlled or treated. Furthermore, balloon-assisted enteroscopy is a valuable diagnostic tool for evaluating obscure GI bleeding and identifying and removing small tumors or other abnormal growths.

Imaging:

Imaging modalities⁸B. W. Carney, G. Khatri, and A. S. Shenoy-Bhangle, “The role of imaging in gastrointestinal bleed,” Cardiovasc. Diagn. Ther., vol. 9, no. Suppl 1, p. S88, Aug. 2019, doi: 10.21037/CDT.2018.12.07. such as X-ray abdomen erect and CT abdomen can help rule out different causes of GI bleeding. Moreover, imaging can provide information on the extent and severity of the bleeding, guide further diagnostic tests or interventions, and monitor the effectiveness of treatment.

What treatment options are available for Gastrointestinal Hemorrhage?

Apart from endoscopy, the following treatment modalities may also be used:

Medications:
Depending on the cause of the bleeding, doctors may prescribe medications such as acid suppressants, antibiotics, or anti-inflammatory drugs to reduce inflammation or treat infections.

Blood transfusion
If a person has lost significant blood, doctors may transfuse blood products such as red blood cells or platelets to restore the blood volume and prevent further complications.

Surgery:
If your GI bleeding is significant and noninvasive tests cannot locate the source, you may require surgery so doctors can examine the entire small intestine. Fortunately, this is uncommon.

Supportive care:
People with GIT bleeding may require supportive care such as intravenous fluids, electrolyte replacement, and nutritional support to maintain their health and prevent complications.

When Gastrointestinal Hemorrhage is an emergency?

One of the life-threatening complications of GI bleeding is shock. Shock is defined as the inadequate blood supply to the tissues and is potentially fatal if not corrected quickly. To avoid serious harm, you must know its symptoms/signs, including ⁹A. Granholm et al., “Predictors of gastrointestinal bleeding in adult ICU patients: a systematic review and meta-analysis,” Intensive Care Med., vol. 45, no. 10, pp. 1347–1359, Oct. 2019, doi: 10.1007/S00134-019-05751-6/METRICS.:

• A fall in blood pressure
• Inability to urinate or pee frequently and in large amounts
• A quick pulse
• Unconsciousness

Call your local emergency medical number immediately if you or someone else notices the shock symptoms. Seek emergency medical attention if you are vomiting blood, have blood in your stools, or have black, tarry stools.

What are the complications of untreated Gastrointestinal Hemorrhage?

Bleeding in the digestive tract could indicate a severe and potentially fatal condition. Getting medical advice as soon as possible¹⁰L is necessary. Laine, H. Yang, S. C. Chang, and C. Datto, “Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009,” Am. J. Gastroenterol., vol. 107, no. 8, pp. 1190–1195, Aug. 2012, doi: 10.1038/AJG.2012.168..
Untreated GI bleeding can lead to significant problems such as:

• Heart attack
• Infection shock
• Respiratory distress
• Death

Conclusion

In conclusion, GIT bleeding is a serious condition that requires prompt medical attention. Additionally, GI bleeding can lead to significant morbidity and mortality if not diagnosed and treated promptly. Managing GIT bleeding involves identifying the underlying cause and severity and implementing appropriate treatment strategies. Furthermore, early recognition and intervention can reduce the need for blood transfusions, hospitalization, and surgery.
However, the best approach depends on individual circumstances, and you will need a multidisciplinary team to provide optimal care. This team may include gastroenterologists, hematologists, radiologists, surgeons, and critical care specialists. Moreover, effective management of GIT bleeding requires a coordinated and systematic approach, with careful attention to patient monitoring and supportive care.
Timely intervention and appropriate treatment can successfully manage many cases of GIT bleeding, enabling the person to recover fully. Therefore, early detection, prompt referral, and effective treatment are essential for improving outcomes and reducing morbidity and mortality associated with GIT bleeding.

Refrences

• 1
  M. Feinman and E. R. Haut, “Upper Gastrointestinal Bleeding,” Surg. Clin. North Am., vol. 94, no. 1, pp. 43–53, Feb. 2014, doi: 10.1016/j.suc.2013.10.004.
• 2
  J. L. Goldstein and B. Cryer, “Gastrointestinal injury associated with NSAID use: A case study and review of risk factors and preventative strategies,” Drug. Healthc. Patient Saf., vol. 7, pp. 31–41, Jan. 2014, doi: 10.2147/DHPS.S71976.
• 3
  F. Guo, J. Wang, K. Liu, Z. Zeng, and F. Luo, “Case Report Small-cell lung cancer with Mallory-Weiss syndrome as the prominent manifestation,” Int J Clin Exp Pathol, vol. 12, no. 7, pp. 2758–2762, 2019, Accessed: Feb. 09, 2023. [Online]. Available: www.ijcep.com/
• 4
  T. Adegboyega and D. Rivadeneira, “Lower GI Bleeding: An Update on Incidences and Causes,” Clin. Colon Rectal Surg., vol. 33, no. 1, pp. 28–34, 2020, doi: 10.1055/S-0039-1695035/ID/JR00961-59.
• 5
  M. Feinman and E. R. Haut, “Lower Gastrointestinal Bleeding,” Surg. Clin. North Am., vol. 94, no. 1, pp. 55–63, Feb. 2014, doi: 10.1016/j.suc.2013.10.005.
• 6
  A. D. Hopper and D. S. Sanders, “Upper GI bleeding requires prompt investigation,” Practitioner, vol. 255, no. 1742, pp. 15–20, Jul. 2011, Accessed: Feb. 09, 2023. [Online]. Available: https://go.gale.com/ps/i.do?p=AONE&sw=w&issn=00326518&v=2.1&it=r&id=GALE%7CA334170291&sid=googleScholar&linkaccess=fulltext
• 7
  L. Fisher et al., “The role of endoscopy in managing obscure GI bleeding,” Gastrointest. Endosc., vol. 72, no. 3, pp. 471–479, Sep. 2010, doi: 10.1016/J.GIE.2010.04.032.
• 8
  B. W. Carney, G. Khatri, and A. S. Shenoy-Bhangle, “The role of imaging in gastrointestinal bleed,” Cardiovasc. Diagn. Ther., vol. 9, no. Suppl 1, p. S88, Aug. 2019, doi: 10.21037/CDT.2018.12.07.
• 9
  A. Granholm et al., “Predictors of gastrointestinal bleeding in adult ICU patients: a systematic review and meta-analysis,” Intensive Care Med., vol. 45, no. 10, pp. 1347–1359, Oct. 2019, doi: 10.1007/S00134-019-05751-6/METRICS.
• 10
  L is necessary. Laine, H. Yang, S. C. Chang, and C. Datto, “Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009,” Am. J. Gastroenterol., vol. 107, no. 8, pp. 1190–1195, Aug. 2012, doi: 10.1038/AJG.2012.168.