digestive disorders
Gastrointestinal Bleeding
Evaluation of Gastrointestinal Bleeding
GI bleeding typically requires evaluation by a doctor. The following information can help people decide when a doctor’s evaluation is needed and help them know what to expect during the evaluation. In people with GI bleeding, certain symptoms and characteristics are cause for concern. They include Fainting (syncope) Sweating (diaphoresis) Rapid heart rate (over 100 beats per minute) Passing in stool or vomiting more than 1 cup (250 milliliters) of blood People who have GI bleeding should see a doctor right away unless the only sign of bleeding is blood on the toilet paper after a bowel movement. If people with such findings have no warning signs and feel otherwise well, a delay of a day or two is not harmful. Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the GI bleeding and the tests that may need to be done (see table Some Causes and Features of Gastrointestinal Bleeding ). The history is focused on finding out exactly where the bleeding is coming from, how rapid it is, and what is causing it. Doctors need to know how much blood (for instance, a few teaspoons or several clots) is being passed and how often blood is being passed. People with hematemesis are asked whether blood was passed the first time they vomited or only after they vomited a few times with no blood. Doctors ask people with rectal bleeding whether pure blood was passed; whether it was mixed with stool, pus, or mucus; or whether blood simply coated the stool. People with bloody diarrhea are asked about recent travel or other possible forms of exposure to other agents that can cause digestive tract illness (for instance, bacterial infections). Doctors then ask about symptoms of abdominal discomfort, weight loss, and easy bleeding or bruising and symptoms of anemia (such as weakness, easy exhaustion [fatigability], and dizziness). Doctors need to know about any current or past digestive tract bleeding and the results of any previous colonoscopy (an examination of the entire large intestine, the rectum, and the anus using a flexible viewing tube). People should tell doctors whether they have Overview of Inflammatory Bowel Disease (IBD) , bleeding tendencies, or liver disease and whether they use any medications that increase the likelihood of bleeding (such as The physical examination is focused on the person’s vital signs (such as pulse, breathing rate, blood pressure, and temperature) and other indicators of shock or a decrease in the volume of circulating blood (hypovolemia—rapid heart rate, rapid breathing, pallor, sweating, little urine production, and confusion) and anemia. Doctors also look for small purplish red (petechiae) and bruise-like (ecchymoses) spots on the skin, which are signs of bleeding disorders. Doctors also look for signs of chronic liver disease (such as spider angiomas, fluid in the abdominal cavity [ Ascites ], and red palms) and Doctors do a rectal examination to look at stool color and check it for blood and to search for tumors and Anal Fissure . Doctors also examine the anus to look for The need for tests depends on what doctors find during the history and physical examination, particularly whether warning signs are present. There are four main testing approaches to GI bleeding: Blood tests and other laboratory studies Upper endoscopy for suspected upper GI tract bleeding Colonoscopy for lower GI tract bleeding (unless clearly caused by hemorrhoids) Angiography or CT angiography if bleeding is rapid or severe The person’s blood count helps indicate how much blood has been lost. A low platelet count is a risk factor for bleeding. Other blood tests include prothrombin time (PT), partial thromboplastin time (PTT), and liver tests, all of which help detect problems with blood clotting. Doctors often do not do blood tests on people who have minor bleeding caused by hemorrhoids. If the person has vomited blood or dark material (which may represent partially digested blood), the doctor sometimes passes a small, hollow plastic tube through the person’s nose down into the stomach (nasogastric tube—see Intubation of the Digestive Tract ) and suctions out the stomach contents. Bloody or pink contents indicate active upper GI bleeding, and dark or coffee-ground material indicates that bleeding is slow or has stopped. Sometimes, there is no sign of blood even though the person was bleeding very recently. A nasogastric tube may be inserted in anyone who has not vomited but has passed a large amount of blood from the rectum (if not from an obvious hemorrhoid) because this blood may have originated in the upper digestive tract. If the nasogastric tube reveals signs of active bleeding, or the person’s symptoms strongly suggest the bleeding is originating in the upper digestive tract, the doctor usually does upper endoscopy. Upper Endoscopy is a visual examination of the esophagus, stomach, and the first segment of the small intestine (duodenum) using a flexible tube called an endoscope. An upper endoscopy allows the doctor to see the bleeding source and often treat it and is often done without a nasogastric tube being passed. People with symptoms typical of hemorrhoids may need only sigmoidoscopy (examination of the lower part of the large intestine, the rectum, and anus using an endoscope) or anoscopy (examination of only the rectum, using a short scope and light source). All other people with hematochezia should have colonoscopy (examination of the entire large intestine, the rectum, and the anus using an endoscope). Occasionally, upper endoscopy and colonoscopy do not show the cause of bleeding. There are still other options for finding the source of the bleeding. Doctors may do endoscopy of the small bowel (enteroscopy). If bleeding is rapid or severe, doctors sometimes do Angiography . During angiography, doctors use a catheter to inject an artery with a contrast agent that can be seen on x-rays. Angiography helps doctors diagnose upper digestive tract bleeding and allows them to do certain treatments (such as embolization and vasoconstrictor infusion—see Doctors may do a small-bowel follow-through, which is a series of detailed x-rays of the small intestine. This test has largely been replaced by CT Enterography and MR Enterography , which is used to evaluate the inside of the small intestine for tumors. Another option is Video Capsule Endoscopy , in which people swallow a tiny camera that takes pictures as it passes through the intestines. Video capsule endoscopy is especially useful in the small intestine, but it is not very useful in either the colon or stomach because these organs are easier to see using endoscopy. 