Gastrointestinal Bleeding

COMMON CAUSES OF HEMATEMESIS

Peptic ulcer disease
Gastritis
Esophagitis
Mallory-Weiss tear^*
Esophageal varices^*

LESS COMMON CAUSES OF HEMATEMESIS NOT TO BE MISSED

Artifactual causes
Aortoenteric fistula^*
Occult blood ingestion
Malignancy

COMMON CAUSES OF RECTAL BLEEDING OR MELENA

Hemorrhoidal bleeding^*
Colorectal carcinoma^*
Diverticulosis
Any cause of brisk upper tract bleeding
Inflammatory bowel disease
Infectious diarrhea

LESS COMMON CAUSES OF RECTAL BLEEDING OR MELENA NOT TO BE MISSED

Angiodysplasia of the colon
Meckel diverticulum
Osler-Weber-Rendu syndrome

HISTORY

Epigastric or right upper quadrant discomfort, often described as “gnawing” or “burning,” may be reported in patients with peptic ulceration involving either the stomach and distal esophagus or the duodenum. The history may reveal that discomfort
is relieved with food or antacid intake and that it often recurs several hours after eating. Recent or chronic ingestion of steroids, aspirin, or other nonsteroidal antiinflammatory agents, or antithrombotic and antiplatelet therapy may predispose to gastrointestinal bleeding. Lower quadrant discomfort may be present in patients with diverticulitis, inflammatory bowel disease, and infectious diarrhea.

A variety of substances, including licorice, beets, spinach, chard, charcoal, coal, dirt, lead, iron, bismuth (Pepto-Bismol), and sulfobromophthalein, may sufficiently discolor either the gastric contents or stool to produce alarm; these artifactual causes may be established by history and actual blood loss excluded by a negative stool guaiac determination.

Hematemesis beginning after an initial bout of retching is often caused by the development of a Mallory-Weiss mucosal laceration. In Laennec cirrhosis, one half of patients presenting with hematemesis are bleeding from a nonvariceal source.

A history of narrowing of the caliber of stools and weight loss is suggestive of colorectal carcinoma. Perianal pain or pruritus is commonly reported in patients with hemorrhoids. A family history of gastrointestinal bleeding suggests the Osler-Weber-Rendu syndrome.

PHYSICAL EXAMINATION

Abdominal tenderness is noted in peptic ulcer, diverticulitis, inflammatory bowel disease, colorectal carcinoma, and infectious diarrhea.
Signs of hyperestrogenism secondary to chronic liver disease, including gynecomastia and testicular atrophy, support the diagnosis of significant liver damage, which may be associated with portal hypertension and esophageal varices.
External hemorrhoids are seen on inspection of the rectum; internal hemorrhoids, which are much more likely to produce significant hemorrhage, are best documented by anoscopy or proctosigmoidoscopy. Because 60% to 70% of all colorectal cancers arise in the rectosigmoid, digital rectal examination may detect such lesions.

DIAGNOSTIC TESTS

Stable patients presenting with hematemesis require passage of a nasogastric tube and a rectal examination for the analysis of occult or gross blood. Admission should be considered in all patients with evidence of upper tract bleeding. Blood should be obtained for typing and cross-matching, determination of hematocrit and clotting parameters, and other routine admission studies. A negative nasogastric aspirate for occult blood does not exclude an upper tract source. In approximately 25% of patients with duodenal bleeding, a competent pyloric sphincter prevents reflux of blood into the stomach resulting in negative NG aspirates for blood.

Only gold members can continue reading. Log In or Register to continue