Acute Gastrointestinal Bleeding: Diagnosis and Treatment (Clinical Gastroenterology)

Although bright red blood per rectum is usually indicative of a lower GI source, it may Please enter User Name Password Error: Please enter Password Forgot Username? Use this site remotely Bookmark your favorite content Track your self-assessment progress and more! Otherwise it is hidden from view. About MyAccess If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. Sign in via OpenAthens. Sign in via Shibboleth.

Clinical Sports Medicine Collection. Search Advanced search allows to you precisely focus your query. Search within a content type, and even narrow to one or more resources. You can also find results for a single author or contributor. Acute Upper Gastrointestinal Bleeding.

Accessed December 17, Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. Systematic review and meta-analysis of adverse events of low-dose aspirin and clopidogrel in randomized controlled trials. Please enter User Name. View All Subscription Options. Patients with massive GI hemorrhage with hemodynamic instability are recommended to proceed directly to catheter angiography or urgent surgery[ 38 ]. Catheter angiography can detect bleeding at rates of 0. It is used often in suspected acute lower GI bleeding due to anatomical availability of end arteries and is more challenging in acute upper GI bleeding due to the presence of multiple collateral vessels[ 62 ].

It also does not require bowel preparation. Other factors that may affect the sensitivity of angiography include intermittent bleeding, procedural delays, atherosclerotic anatomy, and venous or small vessel bleeding[ 64 , 65 ]. Complications include access-site hematoma or pseudoaneurysm, arterial dissection or spasm, bowel ischemia, and contrast-induced nephropathy or allergic reaction.

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The threshold rate of GI bleeding for localization with radionuclide scanning is 0. Nuclear scans are either technetiumm 99m Tc sulphur colloid or 99m Tc pertechnetate-labelled autologous red blood cells. The short half-life of 99m Tc sulphur colloid is a limitation as this means that patients must be actively bleeding during the few minutes the label is present in the intravascular space, and repeat scanning for intermittent bleeding is not possible without reinjection.

The main disadvantage of this test is poor anatomic localization of the bleeding site, and this poorly predicts subsequent angiogram results[ 68 , 69 ]. Furthermore, radionuclide only provides functional data, and is unable to diagnose the pathological cause of GI bleeding. Although advocated as a guide for surgical resection, surgical planning should not be based on only a positive nuclear scan[ 70 ]. All imaging studies have the advantage of allowing the clinician to identify the location of bleeding throughout the GI tract, especially those originating from the small bowel.

However, their use is often limited by the need for active bleeding at the time of investigation. Other diagnostic modalities such as push enteroscopy, deep small bowel enteroscopy and capsule endoscopy may be of value when the above described investigations prove to be non-diagnostic and when patients are hemodynamically stable with low volume bleeding.

These studies will be discussed in the subsequent section evaluating chronic occult GI bleeding. Iron deficiency is the most common cause of anemia worldwide. In developed countries the major cause of iron deficiency is secondary to chronic blood loss[ 71 ]. Iron deficiency anemia has traditionally been attributed to chronic occult GI bleeding, especially in groups other than premenopausal women, and warrants further investigation of the gastrointestinal tract, including for colorectal cancer[ 12 ]. Chronic occult GI bleeding may occur anywhere in the GI tract, from the oral cavity to the anorectum[ 73 ].

Causes of chronic occult GI bleeding can be broadly categorized into mass lesions, inflammatory, vascular, and infectious[ 12 ]. More common causes include colorectal cancer especially right-sided colon , severe esophagitis, gastric or duodenal ulcers including from the use of aspirin and other NSAIDs, inflammatory bowel disease, gastric cancer, celiac disease, vascular ectasias any site , diverticula, and portal hypertensive gastropathy.

A small bowel source accounts for a high percentage of patients with chronic occult GI bleeding and negative findings on upper endoscopy and colonoscopy[ 10 ], which is classified as obscure GI bleeding. Patients with iron deficiency anemia may or may not be symptomatic.

Rockey[ 75 ] recommended that initial investigation be directed towards the location of specific symptoms if possible. In the absence of symptoms, particularly in the elderly, the colon should be evaluated first, and if this is negative, upper GI tract is further investigated[ 75 ]. A targeted history is of value to discern symptoms of unintentional weight loss suggestive of malignancy , use of aspirin or other NSAIDs ulcerative mucosal injury , antiplatelet or anticoagulant use, family history, liver disease, and previous gastrointestinal tract surgery[ 76 ]. Physical signs could indicate presence of an underlying condition such as celiac disease, inflammatory bowel disease, Plummer-Vinson syndrome, and Peutz-Jeghers syndrome[ 74 ].

The choice and sequence of procedures will depend on clinical suspicion and symptoms[ 10 ]. Endoscopic measures include upper endoscopy, colonoscopy, deep enteroscopy, or capsule endoscopy. CT colonography, CT and magnetic resonance MR enterography are some of the radiographic investigations utilized in the evaluation of patients with chronic occult GI bleeding.

The role of barium enema, small bowel series, enteroclysis, standard CT or MR imaging and nuclear scans have substantially declined due to their low diagnostic yield and the advent of capsule endoscopy[ 11 ]. The choice of investigation should also incorporate consideration of patient risk factors and preference. In general, colonoscopy and upper endoscopy are the initial investigations of choice for chronic occult GI bleeding[ 11 ]. The American Gastroenterological Association guidelines on obscure GI bleeding recommended that the evaluation of a patient with a positive FOBT depends upon whether iron deficiency anemia is present.

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Patients with positive FOBT and no anemia should first be investigated with a colonoscopy if upper GI symptoms present then also upper endoscopy whereas patients with iron deficiency anemia should undergo both upper endoscopy and colonoscopy[ 11 ]. Patients with negative findings on upper endoscopy and colonoscopy without anemia do not require further investigations, but those with anemia should be referred for further investigation of the small bowel.

The initial small bowel investigation of choice, when available, is wireless capsule endoscopy[ 11 ]. Capsule endoscopy also avoids the higher rates of morbidity and mortality associated with push enteroscopy[ 82 ]. Complications related to the procedure are rare and include capsule retention and obstruction[ 83 ]. Push enteroscopy can evaluate the GI tract to cm of the proximal jejunum.

However, with the availability of deep enteroscopy, which can reach to the distal small bowel, the use of push enteroscopy has diminished. Three systems widely used are: Studies comparing the three different modalities are lacking.

Diagnosis of gastrointestinal bleeding: A practical guide for clinicians

The advantage of deep enteroscopy over capsule endoscopy is that it can also be a therapeutic modality. CT enterography involves ingestion of a neutral contrast agent to distend the small bowel which enables better evaluation of the small bowel wall in comparison to barium solutions. The alternative is MR enterography which has the advantage of not using ionizing radiation allowing serial imaging of the small bowel. Compared to capsule endoscopy, CT enterography provides better visualization of the entire small bowel wall and shows extra-enteric complications of small bowel disease, whereas capsule endoscopy allows direct visualization of the small bowel mucosa and has a higher sensitivity for mucosal processes[ 86 ].

It is defined as recurrent bleeding when the source remains unidentified after endoscopic procedures and is most commonly caused by bleeding from the small intestine. The commonest causes of obscure GI bleeding include small bowel tumors, vascular anomalies such as angiodysplasias and varices, diverticula and Celiac disease. The emphasis in diagnosis of obscure GI bleeding is the investigation of the small bowel[ 76 ].

The already mentioned small bowel investigations using capsule endoscopy and deep enteroscopy techniques including double-balloon enteroscopy, single-balloon enteroscopy and spiral enteroscopy have enabled the diagnosis of substantially more cases of obscure GI bleeding. Capsule endoscopy has the major advantage of being less invasive than deep enteroscopy but the major advantage of deep enteroscopy techniques is their ability to perform treatment at the same time.

The choice between capsule endoscopy and deep enteroscopy should be individualized for each patient and one approach may be initial capsule endoscopy followed by a directed deep enteroscopy as directed intervention[ 76 ]. CT or MR enterography may be considered as an alternative investigation for small bowel disease due to its ability to visualize the small bowel wall and extra-enteric complications, especially when capsule endoscopy and deep enteroscopy are non-diagnostic. In patients with signs of active bleeding, the above mentioned technetium radionuclide scan, CT angiography and catheter angiography should be considered to help locate the lesion prior to intervention.

GI bleeding can be caused by a wide range of pathologies and they differ in onset, location, risk and clinical presentation. In patients with active GI bleeding who are unstable, acute resuscitation should precede any investigations. Accurate clinical diagnosis is crucial in determining the investigation of choice and specific treatment interventions. Angiography and radionuclide imaging are best suited for acute overt GI bleeding.

Wen LL L- Editor: National Center for Biotechnology Information , U. World J Gastrointest Pathophysiol. Published online Nov Author information Article notes Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract Gastrointestinal bleeding is a common problem encountered in the emergency department and in the primary care setting.

Gastrointestinal hemorrhage, Diagnostic techniques, Endoscopy, Colonoscopy, Capsule endoscopy, Enteroscopy, Computed tomography, Angiography.

INTRODUCTION

Upper vs lower Upper GI bleeding includes hemorrhage originating from the esophagus to the ligament of Treitz, at the duodenojejunal flexure[ 13 ]. Etiology and pathophysiology Acute upper GI bleeding may originate in the esophagus, stomach, and duodenum. Initial evaluation Rapid assessment and resuscitation should precede diagnostic evaluation in unstable patients with acute severe bleeding[ 27 ]. Upper endoscopy In patients with acute upper GI bleeding, upper endoscopy is considered the investigation of choice[ 35 ].

Open in a separate window. Colonoscopy In acute lower GI bleeding, the diagnostic approach is somewhat more variable.

Diagnosis of gastrointestinal bleeding: A practical guide for clinicians

CT angiography CT angiography requires the rate of ongoing arterial bleeding to be at least 0. Catheter angiography Catheter angiography can detect bleeding at rates of 0.

Radionuclide imaging The threshold rate of GI bleeding for localization with radionuclide scanning is 0. Etiology and pathophysiology Chronic occult GI bleeding may occur anywhere in the GI tract, from the oral cavity to the anorectum[ 73 ]. Clinical presentation Patients with iron deficiency anemia may or may not be symptomatic.

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Colonoscopy and upper endoscopy The American Gastroenterological Association guidelines on obscure GI bleeding recommended that the evaluation of a patient with a positive FOBT depends upon whether iron deficiency anemia is present. Nature and magnitude of the problem in the U. Management of gastrointestinal hemorrhage.

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