Diagnosis of

Gastrointestinal Bleeding

Liu Zhenhua
Hematemesis and Hematochezia
 The approach to gastro-
intestinal (GI) bleeding is
tailored to the manner of
appearance
 Recognition of hemorrhage

Is bleeding acute or chronic?

Intensive care

Where is the source of bleeding?

What is the causes of bleeding?

Diagnosis Empiric therapy

Treatment
 Recognition of hemorrhage

Is bleeding acute or chronic?

Intensive care

Where is the source of bleeding?

What is the causes of bleeding?

Diagnosis Empiric therapy

( 经验治疗 )
Treatment
 Recognition of hemorrhage

Clinical Manifestations
1 Manner of bleeding presentation
2 Hypovolemia or shock
3 Anemia
 Manner of bleeding presentation
Patients manifest blood loss

from the GI tract in five ways:

1) Hematemesis
Bloody vomitus, either fresh and
bright red or older and “coffee -
ground” (Acidic hematin) in character
Hemoptysis?
Nosebleeding?
 Manner of bleeding presentation

2) Melena
 Shiny, black, sticky (tarry stool), foul-
smelling
 Degradation of blood
 Exogenous stool darkeners
iron
bismuth
 Manner of bleeding presentation

3) Hematochezia
bright red or maroon blood from the
rectum
 pure blood
 blood intermixed with formed stool
 bloody diarrhea
 Manner of bleeding presentation

4) Occult
detected only by testing the stool
with a monoclonal antibody for human

hemoglobin
 Estimate amount of bleeding from
upper GI tract

5~10 ml/d OB +

50~70 ml/d Melena

250~300 ml in short time Hematemesis

 Manner of bleeding presentation

5) other symptoms of blood loss

dizziness, dyspnea, angina or
even shock
 Blood loss

Sympathetic-adrenal medulla system

Catecholamine

Ischemia Secretion of
Tachycardia
of skin sweat gland Visceral vascular
contraction

Pulse Pale Oliguria

Sweating
Cold extremities Rectal temperature
 Hypovolemia or shock

Speed and volume of blood loss

Weakness, giddiness, oliguria, cold extremity,

sweating

Vital signs: tachycardia, hypotention

 Anemia

pale fatigability
dizziness dyspnea
palpitation angina
 Is bleeding acute or chronic?

1) Bleeding speed
Hematemesis of fresh blood generally
indicates a more severe bleeding episode
than melena, which occurs when bleeding is
slow enough to allow time for degradation of

blood
 Is bleeding acute or chronic?

2) Blood pressure and heart rate

depend on
 amount of blood loss

 suddenness of blood loss

 extent of cardiac and vascular

compensation
 Is bleeding acute or chronic?

postural hypotension
---- early physical finding

tachycardia

---- greater loss, compensate

recumbent hypotension

---- final results

 Is bleeding acute or chronic?

Postural hypotension
A postural drop in blood pressure of 10 to
20 mm Hg
 Is bleeding acute or chronic?

3) Bowel sound

Active bowel sound usually be presented in

acute bleeding from GI tract

 Is bleeding acute or chronic?

4) Hematocrit
 bleeding slowly

 hypochromic microcytic red blood cells

 mean corpuscular volume (MCV) of the cells

may be low
 Is bleeding acute or chronic?

If blood loss is acute, the hematocrit

dose not change during the first few hours
after hemorrhage
About 24 to 72 hours later, plasma
volume is larger than normal and the
hematocrit is at its lowest point
 Is bleeding acute or chronic?
7
6

Volume 3
2 45
(Liters) %
45 27
1 % %

A B C
Hematocrit changes
A Before bleeding
B Immediately after bleeding
C 24~72 hours after bleeding
 Emergent and intensive care

Initially
vital signs
• supine and upright
blood pressure
• pulse
If blood loss is significant, intravenous
fluids must be started

Saline or other
balanced electrolyte
solutions are most
rapidly available
 Blood is sent to the lab
complete blood count
clotting studies
routine chemistry studies

 Blood for typing and cross-matching is

sent to the blood bank
Where is the source of bleeding?
Localization

Upper GI bleeding: bleeding from a

source proximal to the ligament of
Treitz.
Lower GI bleeding: bleeding from a
site distal to the ligament of Treitz.
 Localization

Treitz:

The ligament of Treitz is an

anatomic landmark for the
duodenal-jejunal junction
 Localization
Differentiating features of
upper GI and lower GI bleeding

Upper GI Lower GI

Manifestation Hematemesis Hematochezia

melena
Nasogastric
aspirate Bloody Clear
BUN Elevated Normal
Bowel sound Hyperactive Normal
 More proximal lesions produce

hematemesis or melena, whereas more

distal lesions are more likely to produce
hematochezia
 If hematochezia is

from an upper GI
source, it usually
reflects a massive
bleed (i. e. , greater
than 1000 ml).
 What is the causes of bleeding?

90% upper GI bleeding is due to four

lesions:
1) peptic ulcer
2) hemorrhagic gastritis
3) esophageal or gastric varices
4) gastric cancer
peptic ulcer
hemorrhagic gastritis
esophageal varices
gastric cancer
 Causes of gastrointestinal bleeding

 Mallory-Weiss tear

Portal-hypertensive gastropathy

Ancylostomiasis

Post-sphincterotomy
 Causes of gastrointestinal bleeding

• Colorectal cancer

• Colitis

• Large hemorrhoid

• Rectum tear

• Vascular anomalies

• Hematologic diseases
 Diagnostic approach to
gastrointestinal bleeding

1 History and physical examination

2 Endoscopy
3 Barium radiography
4 Angiography
5 Nuclear scintigraphy
 Diagnostic approach to GI bleeding

History and physical examination

A history of previously documented

GI tract disease determined by
radiography, endoscopy, or surgical
procedures is very useful.
 Diagnostic approach to GI bleeding

A history of epigastric burning pain

promptly relieved by food or antacids or
nocturnal pain suggests peptic ulcer
disease, particularly duodenal ulcer
 Diagnostic approach to GI bleeding

Localized epigastric tenderness to

palpation may indicate peptic ulcer disease

or gastritis
 Diagnostic approach to GI bleeding

Patients with hepatitis B or

chronic active liver disease may
present with painless hematemesis
from esophageal varices.
 Diagnostic approach to GI bleeding

Patients with stigmata of chronic liver

disease [e.g., spider angioma, ascites,
gynecomastia] and upper GI bleeding often
bleed from esophageal varices or erosion
 Diagnostic approach to GI bleeding

Patients with forceful, retching or multiple

episodes of vomiting of food prior to the onset
of hematemesismay be bleeding from Mallory－
Weiss tears of the gastroesophageal junction.
 Diagnostic approach to GI bleeding

Colorectal malignancy is often suggested by

a history of
gradual weight loss
intermittent blood in the stools
altered bowel habits
 Diagnostic approach to GI bleeding

Hemorrhoidal bleeding is often

suggested by the presence of bright red
blood surrounding well-formed, normal-
appearing stools.
 Diagnostic approach to GI bleeding

A rectal examination is essential to

document stool color as well as to palpate for
gross ano-rectal mass lesions such as polyps,
cancers, or large hemorrhoids.
 Diagnostic approach to GI bleeding

Endoscopy
Endoscopy is the diagnostic
procedure of choice because of
its high accuracy and immediate
therapeutic potential
Endoscopy, however, must be
performed only following adequate
resuscitation
 Diagnostic approach to GI bleeding

Barium radiography
Barium radiography is noninvasive
but has significant disadvantages,
particularly in patients who are bleeding
briskly (actively)
 Diagnostic approach to GI bleeding

Angiography
Angiography may localize the site of
bleeding
 Diagnostic approach to GI bleeding

Angiography
Bleeding must be active because
angiography detects only extravasation of
contrast into the GI tract
Think about：
 What is the clinical manifestations of GI tract

bleeding ？

 What are the possible causes of GI tract

bleeding?