Gastrointestinal bleeding

What is gastrointestinal bleeding?

Gastrointestinal bleeding is bleeding from anywhere in the digestive tract, and it is a sign of another condition. Upper GI bleeding comes from the oesophagus, stomach or duodenum. Lower GI bleeding comes from most of the small intestine, the colon, rectum or anus. It can be heavy and sudden, or slow and hidden.

Slow, hidden bleeding may show only as anaemia or a positive stool test. Even small amounts of bleeding over a long time can lead to a low blood count.

What causes gastrointestinal bleeding?

Common causes of GI bleeding include piles, anal fissures, stomach and duodenal ulcers, diverticular disease, ulcerative colitis and Crohn's disease. Polyps and cancers of the bowel, stomach or oesophagus can also bleed. Abnormal blood vessels, varices from liver disease, and medicines such as aspirin, anti-inflammatory painkillers and blood thinners are other causes.

• Piles (haemorrhoids) and anal fissures, common causes of bright red blood on the paper
• Stomach or duodenal ulcers and inflammation of the stomach lining
• Diverticular disease of the colon
• Ulcerative colitis and Crohn's disease
• Bowel polyps and cancers of the colon, stomach or oesophagus
• Abnormal blood vessels in the bowel lining (angiodysplasia)
• Enlarged veins in the oesophagus or stomach (varices), usually linked to liver disease
• Medicines such as aspirin, anti-inflammatory painkillers and blood thinners, which can cause or worsen bleeding

What are the symptoms?

Signs of upper GI bleeding include vomiting red blood or coffee-ground material, and black, tarry stools. Lower GI bleeding usually shows as red blood on the paper, in the bowl or mixed with stool, or as dark blood in the stool. Slow bleeding may only cause tiredness or breathlessness from anaemia.

• Vomiting bright red blood or material that looks like coffee grounds
• Black, tarry stools
• Dark blood mixed with the stool
• Bright red blood on the toilet paper, in the bowl or coating the stool
• Tiredness or breathlessness from anaemia when bleeding is slow

When is GI bleeding an emergency?

Go to an emergency department straight away if you vomit blood, pass black stools or a lot of red blood, or feel faint, dizzy, clammy or breathless. Small or recurrent bleeding still needs a prompt clinic review, particularly with a change in bowel habit, weight loss or tiredness.

The warning signs below need prompt attention.

• Vomiting blood, especially with feeling faint, dizzy, pale or clammy
• A lot of blood from the back passage, such as the toilet water turning red or large clots
• Black, tarry stools
• Chest pain, breathlessness or severe abdominal pain with bleeding
• Bleeding while taking blood-thinning medicines

How is it diagnosed?

GI bleeding is diagnosed by a history, examination including a rectal check, and blood tests for blood count and clotting. Gastroscopy examines the upper tract and colonoscopy the large bowel. In heavy bleeding, CT angiography can locate an active bleeding point. The choice of test depends on where the bleeding is likely to come from.

• Questions about the colour and amount of blood, your bowel habit and your medicines
• Examination, including a gentle rectal examination
• Blood tests for blood count, clotting and kidney function
• Gastroscopy to examine the oesophagus, stomach and duodenum
• Colonoscopy to examine the large bowel
• CT angiography to locate active bleeding in selected patients with heavy bleeding

How is gastrointestinal bleeding treated?

Treatment starts with making you stable, with fluids and blood if needed. Many bleeding points can be treated during the same endoscopy that finds them. Medicines are reviewed, acid-reducing medicine is used for ulcers, and embolisation or surgery is used when bleeding cannot be controlled otherwise. The underlying cause is then treated.

• Fluids, and a blood transfusion if needed, to stabilise you first
• Treatment of the bleeding point during endoscopy, in the same procedure that finds it
• Review of blood thinners and anti-inflammatory painkillers, with your other doctors where needed
• Medicines to reduce stomach acid, and treatment of H. pylori infection, for ulcers
• Angiography and embolisation, where a radiologist blocks the bleeding vessel through a fine tube
• Surgery when bleeding cannot be controlled by other means, or to treat the underlying cause
• Treatment of the cause, such as piles, a fissure, polyps or inflammatory bowel disease

What are the risks and complications?

Untreated GI bleeding can cause anaemia and, if heavy, shock. Bleeding can return after it stops, which is why blood thinners are restarted with a clear plan. Endoscopy, sedation, embolisation and surgery each carry their own risks, which are discussed before any procedure.

• Anaemia and fatigue from ongoing blood loss
• Shock if bleeding is heavy and not treated quickly
• Bleeding returning, which is why blood thinners are restarted with a plan
• Small risks from endoscopy, sedation and other procedures, explained before any test
• General risks of surgery and anaesthesia if an operation is needed