Gastrointestinal Bleeding - Causes, Symptoms, First Aid And Diagnosis

2024 Author: Josephine Shorter | [email protected]. Last modified: 2024-01-07 17:49

Causes, symptoms, first aid and diagnosis of gastrointestinal bleeding

Content:

• What is Gastrointestinal Bleeding?
• Causes of gastric bleeding
• Signs and symptoms of gastric bleeding
• First aid for gastrointestinal bleeding
• Complications of gastrointestinal bleeding
• Diagnosis of gastric bleeding
• Treatment of gastrointestinal bleeding
• Diet for gastric bleeding

What is Gastrointestinal Bleeding?

Gastrointestinal bleeding (GCC) is the leakage of blood from blood vessels damaged by the disease in the cavity of the organs of the gastrointestinal tract. Gastrointestinal bleeding is a common and serious complication of a wide range of pathologies of the gastrointestinal tract, which poses a threat to the health and even life of the patient. The volume of blood loss can reach 3-4 liters, so this bleeding requires emergency medical attention.

In gastroenterology, gastrointestinal bleeding ranks 5th in prevalence after appendicitis, pancreatitis, cholecystitis and hernia infringement.

Any part of the gastrointestinal tract can become a source of bleeding. In this regard, bleeding is released from the upper gastrointestinal tract (from the esophagus, stomach, duodenum) and the lower gastrointestinal tract (small and large intestine, rectum).

Bleeding from the upper sections is 80-90%, from the lower sections - 10-20% of cases. More specifically, the stomach accounts for 50% of bleeding, the duodenum 30%, the colon and rectum 10%, the esophagus 5%, and the small intestine 1%. With gastric and duodenal ulcers, bleeding occurs in 25% of cases.

According to the etiological criterion, ulcerative and non-ulcerative GCC are distinguished, according to the nature of the bleeding itself - acute and chronic, according to the clinical picture - overt and hidden, according to the duration - single and recurrent.

The risk group includes men in the 45-60 age group. 9% of people admitted to surgical departments by ambulance services are admitted with gastrointestinal bleeding. The number of its possible causes (diseases and pathological conditions) exceeds 100.

Causes of gastric bleeding

All gastrointestinal bleeding is divided into four groups:

1. Bleeding in diseases and lesions of the gastrointestinal tract (peptic ulcer, diverticula, tumors, hernias, hemorrhoids, helminths, etc.);
2. Bleeding due to portal hypertension (hepatitis, liver cirrhosis, cicatricial strictures, etc.);
3. Bleeding with damage to blood vessels (varicose veins of the esophagus, scleroderma, etc.);
4. Bleeding in blood diseases (aplastic anemia, hemophilia, leukemia, thrombocythemia, etc.).

Bleeding in diseases and lesions of the gastrointestinal tract

In the first group, ulcerative and non-ulcerative HCC are distinguished. Ulcerative pathologies include:

• Stomach ulcer;
• Duodenal ulcer;
• Chronic esophagitis (inflammation of the lining of the esophagus);
• Gastroesophageal reflux disease of the esophagus (develops as a result of a systematic spontaneous reflux of stomach contents into the esophagus);
• Erosive hemorrhagic gastritis;
• Ulcerative colitis and Crohn's disease (pathologies of the large intestine, similar in symptoms, but having a different etiology).

There are also the following reasons leading to acute gastrointestinal ulcers:

• Medication (long-term use of glucocorticosteroids, salicylates, NSAIDs, etc.);
• Stress (mechanical injuries, burns, foreign bodies entering the digestive tract, emotional shock after injuries, operations, etc.);
• Endocrine (Zollinger-Ellison syndrome (secretion of a biologically active substance gastrin by an adenoma (tumor) of the pancreas) hypofunction of the parathyroid glands);
• Postoperative (previously performed operations on the gastrointestinal tract).

Non-ulcer bleeding can be caused by:

• Erosion of the gastric mucosa;
• Mallory-Weiss syndrome (rupture of the mucous membrane at the level of the esophageal-gastric junction with recurrent vomiting);
• Diverticula of the digestive tract (protrusion of the walls);
• Diaphragmatic hernia;
• Bacterial colitis;
• Hemorrhoids (inflammation and pathological expansion of the veins of the rectum, forming nodes);
• Anal fissures;
• Benign tumors of the gastrointestinal tract (polyps, lipoma, neuroma, etc.);
• Malignant tumors of the gastrointestinal tract (cancer, sarcoma);
• Parasitic intestinal lesions;
• Intestinal infections (dysentery, salmonellosis).

Bleeding due to portal hypertension

The cause of gastrointestinal bleeding of the second group can be:

• Chronic hepatitis;
• Cirrhosis of the liver;
• Hepatic vein thrombosis;
• Portal vein thrombosis;
• Compression of the portal vein and its branches with scar tissue or tumor formation.

Bleeding with vascular damage

The third group includes gastrointestinal bleeding caused by damage to the walls of blood vessels. They are caused by the following diseases:

• Atherosclerosis of the vessels of the internal organs;
• Vascular aneurysms (expansion of the lumen of the vessel with a simultaneous thinning of its walls);
• Varicose veins of the esophagus or stomach (often resulting from liver dysfunction);
• Systemic lupus erythematosus (an immune disease that affects connective tissue and capillaries;
• Scleroderma (a systemic disease that causes hardening of small capillaries);
• Hemorrhagic vasculitis (inflammation of the walls of the vessels of internal organs);
• Randu-Osler disease (congenital vascular anomaly, accompanied by the formation of multiple telangiectasias);
• Periarteritis nodosa (damage to the arteries of internal organs);
• Thrombosis and embolism of the vessels of the intestinal mesentery;
• Cardiovascular pathologies (heart failure, septic endocarditis (damage to the heart valves), constrictive pericarditis (inflammation of the pericardial sac), hypertension).

Bleeding with blood diseases

The fourth group of gastrointestinal bleeding is associated with blood diseases such as:

• Hemophilia and von Willebrand disease are genetically determined bleeding disorders);
• Thrombocytopenia (deficiency of platelets - blood cells responsible for blood clotting);
• Acute and chronic leukemia;
• Hemorrhagic diathesis (thrombasthenia, fibrinolytic purpura, etc. - a tendency to recurrent bleeding and hemorrhage);
• Aplastic anemia (impaired function of hematopoiesis of the bone marrow).

Consequently, GCC can occur both due to a violation of the integrity of blood vessels (with their ruptures, thrombosis, sclerosis), and due to violations of hemostasis. Both factors are often combined with each other.

With ulcers of the stomach and duodenum, bleeding begins as a result of the melting of the vascular wall. This usually occurs with the next exacerbation of a chronic disease. But sometimes there are so-called dumb ulcers that do not make themselves felt until bleeding.

In infants, intestinal bleeding is often caused by volvulus. Bleeding with it is rather scanty, the main symptoms are more pronounced: an acute attack of abdominal pain, constipation, non-discharge of gases. In children under the age of three, such bleeding is more often due to anomalies in the development of the intestine, the presence of neoplasms, and diaphragmatic hernia. Colon polyps are most likely in older children: in this case, some blood is released at the end of a bowel movement.

Signs and symptoms of gastric bleeding

Common symptoms of gastrointestinal bleeding are as follows:

• Weakness;
• Nausea, vomiting of blood;
• Dizziness;
• Pale skin, blue lips and fingertips;
• Altered stools;
• Cold sweat;
• Weak, rapid pulse;
• Lowering blood pressure.

The severity of these symptoms can vary widely: from mild malaise and dizziness to deep fainting and coma, depending on the rate and volume of blood loss. With slow, weak bleeding, their manifestations are insignificant, there is a slight tachycardia at normal pressure, since partial compensation for blood loss has time to occur.

GLC symptoms are usually accompanied by signs of an underlying disease. In this case, pain can be observed in different parts of the gastrointestinal tract, ascites, signs of intoxication.

In acute blood loss, short-term fainting is possible due to a sharp drop in pressure. Symptoms of acute bleeding:

• Weakness, drowsiness, severe dizziness;
• Darkening and "flies" in the eyes;
• Noise in ears;
• Shortness of breath, severe tachycardia;
• Increased sweating;
• Cold feet and hands;
• Weak pulse and low blood pressure.

The symptoms of chronic bleeding are similar to those of anemia:

• Deterioration of the general condition, high fatigue, decreased performance;
• Pallor of the skin and mucous membranes;
• Dizziness;
• The presence of glossitis, stomatitis, etc.

The most characteristic symptom of GCC is the admixture of blood in the vomit and stool. Blood in vomit may be present unchanged (with bleeding from the esophagus in the case of varicose veins and erosions) or in an altered form (with stomach and duodenal ulcers, as well as Mallory-Weiss syndrome). In the latter case, vomit has the color of "coffee grounds", due to the mixing and interaction of blood with hydrochloric acid of the contents of gastric juice. Blood in the vomit has a bright red color with profuse (massive) bleeding. If bloody vomiting occurs again after 1-2 hours, most likely, bleeding continues, if after 4-5 hours, this is more indicative of re-bleeding. With bleeding from the lower gastrointestinal tract, vomiting is not observed.

In the stool, blood is present unchanged with a single blood loss exceeding 100 ml (with the outflow of blood from the lower part of the gastrointestinal tract and with a stomach ulcer). In an altered form, blood is present in the stool with prolonged bleeding. In this case, 4-10 hours after the bleeding began, tarry stools of a dark, almost black color (melena) appear. If less than 100 ml of blood enters the gastrointestinal tract during the day, visually changes in the stool are not noticeable.

If the source of bleeding is in the stomach or small intestine, the blood, as a rule, is evenly mixed with the feces; when the rectum flows out, the blood looks like separate clots on top of the feces. Discharge of scarlet blood indicates the presence of chronic hemorrhoids or anal fissure.

It should be taken into account that the stool may have a dark color when eating blueberries, chokeberry, beets, buckwheat porridge, taking activated carbon, iron and bismuth preparations. Swallowing blood during pulmonary or nosebleeds can also cause tarry stools.

For gastric and duodenal ulcers, a decrease in ulcerative pain during bleeding is characteristic. With heavy bleeding, the stool becomes black (melena) and runny. During bleeding, there is no tension in the abdominal muscles and no other signs of irritation of the peritoneum appear.

With stomach cancer, along with the typical symptoms of this disease (pain, weight loss, lack of appetite, change in taste preferences), recurrent, slight bleeding, tarry stools are observed.

With Mallory-Weiss syndrome (rupture of the mucous membrane), profuse vomiting occurs with an admixture of scarlet unchanged blood. With varicose veins of the esophagus, bleeding and its clinical symptoms develop acutely.

With hemorrhoids and anal fissures, scarlet blood can be released at the time of defecation or after it, as well as during physical exertion, it does not mix with feces. Bleeding is accompanied by anal itching, burning, spasms of the anal sphincter.

In cancer of the rectum and colon, bleeding is prolonged, not intense, dark blood is mixed with feces, and mucus may be added.

In ulcerative colitis and Crohn's disease, watery stools mixed with blood, mucus, and pus are observed. With colitis, false urge to defecate is possible. In Crohn's disease, bleeding is predominantly mild, but the risk of heavy bleeding is always high.

Profuse gastrointestinal bleeding has four degrees of severity:

1. The condition is relatively satisfactory, the patient is conscious, the pressure is normal or slightly lowered (not lower than 100 mm Hg), the pulse is slightly increased, since the blood begins to thicken, the level of hemoglobin and erythrocytes is normal.
2. The condition is moderate, there is pallor, heart rate acceleration, cold sweat, the pressure drops to 80 mm Hg. Art., hemoglobin - up to 50% of the norm, blood clotting decreases.
3. The condition is severe, there is lethargy, swelling of the face, pressure below 80 mm Hg. Art., the pulse is above 100 beats. per minute, hemoglobin - 25% of the norm.
4. Coma and the need for resuscitation.

First aid for gastrointestinal bleeding

Any suspicion of HQS is an urgent reason to call an ambulance and deliver a person to a medical facility on a stretcher.

Before the arrival of doctors, you need to take the following first aid measures:

• Lay the person on their back, slightly raising their legs, and ensure complete rest.
• To exclude food intake and not to drink - this stimulates the activity of the gastrointestinal tract and, as a result, bleeding.
• Put dry ice or any other cold object on the area of alleged bleeding - cold narrows the vessels. It is better to apply ice for 15-20 minutes with 2-3-minute breaks to prevent frostbite. Additionally, you can swallow small pieces of ice, but with gastric bleeding, it is better not to risk it.
• You can give 1-2 teaspoons of a 10% solution of calcium chloride or 2-3 crushed Dicinon tablets.

It is forbidden to put an enema and wash the stomach. If you faint, you can try to revive with the help of ammonia. When unconscious, monitor your pulse and breathing.

Complications of gastrointestinal bleeding

Gastrointestinal bleeding can lead to dangerous complications such as:

• hemorrhagic shock (as a consequence of profuse blood loss);
• acute anemia;
• acute renal failure;
• multiple organ failure (stress response of the body, consisting in the cumulative failure of several functional systems).

Untimely hospitalization and self-medication attempts can be fatal.

Diagnosis of gastric bleeding

Gastrointestinal bleeding must be distinguished from pulmonary nasopharyngeal bleeding, in which blood may be swallowed and trapped in the gastrointestinal tract. Likewise, when vomiting, blood can enter the respiratory tract.

Differences between bloody vomiting and hemoptysis:

• Blood leaves with vomiting, and with hemoptysis - during coughing;
• When vomiting, the blood has an alkaline reaction and has a bright red color, with hemoptysis, it is acidic and has a maroon color;
• With hemoptysis, the blood may foam, with vomiting it is not;
• Vomiting is profuse and short-lived, hemoptysis can last for hours or days;
• Vomiting is accompanied by dark stools, with hemoptysis this is not.

Profuse HCC needs to be differentiated from myocardial infarction. With bleeding, the decisive sign is the presence of nausea and vomiting, with a heart attack - chest pain. In women of reproductive age, intra-abdominal bleeding due to ectopic pregnancy should be excluded.

The diagnosis of GCC is established on the basis of:

• Life history and history of the underlying disease;
• Clinical and rectal examination;
• General blood test and coagulogram;
• Analysis of feces for occult blood;
• Instrumental studies, among which the main role belongs to endoscopic examination.

When analyzing the anamnesis, information is obtained about past and existing diseases, the use of certain medications (Aspirin, NSAIDs, corticosteroids) that could provoke bleeding, the presence / absence of alcohol intoxication (which is a common cause of Mallory-Weiss syndrome), the possible impact of harmful working conditions.

Clinical examination

Clinical examination includes examination of the skin (color, presence of hematomas and telangiectasias), digital examination of the rectum, assessment of the nature of vomit and feces. The state of the lymph nodes, the size of the liver and spleen, the presence of ascites, tumor neoplasms and postoperative scars on the abdominal wall are analyzed. Palpation of the abdomen is performed very carefully so that bleeding does not increase. With bleeding of non-ulcer origin, there is no pain response to palpation of the abdomen. Swollen lymph nodes are a sign of a malignant tumor or systemic blood disease.

Yellowness of the skin in combination with ascites may indicate a pathology of the biliary system and allows us to consider varicose veins of the esophagus as a presumed source of bleeding. Hematomas, spider veins and other types of skin hemorrhages indicate the possibility of hemorrhagic diathesis.

On examination, it is impossible to establish the cause of the bleeding, but it is possible to roughly determine the degree of blood loss and the severity of the condition. Confusion, dizziness, flies before the eyes, acute vascular insufficiency indicate brain hypoxia.

It is important to study the rectum with a finger, which helps to analyze the state of not only the intestine itself, but also the adjacent organs. Painful sensations during examination, the presence of polyps or bleeding hemorrhoids allow us to consider these formations as the most likely sources of bleeding. In this case, after manual examination, instrumental (rectoscopy) is performed.

Laboratory methods

Laboratory methods include:

• Complete blood count (analysis of the level of hemoglobin and other main blood cells, counting the leukocyte formula, ESR). In the first hours of bleeding, the blood composition changes insignificantly, only moderate leukocytosis is observed, sometimes a small increase in platelets and ESR. On the second day, the blood thinns, hemoglobin and red blood cells fall (even if the bleeding has already stopped).
• Coagulogram (determination of the period of blood clotting, etc.). After acute profuse bleeding, the activity of blood clotting increases markedly.
• Biochemical blood test (urea, creatinine, liver function tests). Usually, urea rises against the background of normal creatinine levels. All blood tests have diagnostic value only when viewed over time.

Instrumental diagnostic methods:

Instrumental diagnostic methods include:

• X-ray examination determines ulcers, diverticula, other neoplasms, it is not effective for detecting gastritis, erosions, portal hypertension, with bleeding from the intestines.
• Endoscopy is superior in accuracy to X-ray methods and allows you to identify superficial lesions of the mucous membranes of organs. The types of endoscopy are fibrogastroduodenoscopy, rectoscopy, sigmoidoscopy, colonoscopy, which in 95% of cases can determine the source of bleeding.
• Radioisotope studies confirm the presence of bleeding, but are ineffective in determining its exact localization.
• Spiral contrast computed tomography allows you to determine the source of bleeding when it is in the small and large intestines.

Treatment of gastrointestinal bleeding

Patients with acute GCC are admitted to the intensive care unit, where the following measures are taken first of all:

• catheterization of the subclavian or peripheral veins in order to quickly replenish the circulating blood volume and determine the central venous pressure;
• probing and flushing the stomach with cold water to remove accumulated blood and clots;
• catheterization of the bladder to control urine output;
• oxygen therapy;
• a cleansing enema to remove blood flowing into the intestines.

Conservative treatment

Conservative treatment is indicated for:

• hemorrhagic diathesis, vasculitis and other diseases caused by violations of the mechanisms of hemostasis, since in this case the bleeding will become more intense during surgery;
• severe cardiovascular pathologies (heart disease, heart failure);
• severe underlying disease (leukemia, inoperable tumors, etc.).

Conservative therapy includes three groups of therapeutic measures aimed at:

1. Hemostasis system;
2. Source of bleeding;
3. Restoration of the normal volume of circulating blood (infusion therapy).

Etamsilat, Thrombin, Aminocaproic acid, Vikasol are used to influence the hemostatic system. The basic drug is Octreotide, which lowers the pressure in the portal vein, reduces the secretion of hydrochloric acid, and increases the activity of platelets. If oral administration of drugs is possible, Omeprazole, Gastrocepin are prescribed, as well as Vasopressin, Somatostatin that reduce the blood supply to the mucous membranes.

With ulcer bleeding, Famotidine, Pantoprazole are administered intravenously. Bleeding can be stopped by the introduction of liquid Fibrinogen or Dicinon during an endoscopic procedure near the ulcer.

Infusion therapy begins with the infusion of rheological solutions that stimulate microcirculation. In case of 1 degree blood loss, Reopolyglucin, Albumin, Gemodez are administered intravenously with the addition of glucose and salt solutions. With blood loss of the 2nd degree, plasma-substituting solutions and donor blood of the same group and Rh factor are poured in at the rate of 35-40 ml per 1 kg of body weight. The ratio of plasma solutions to blood is 2: 1.

With blood loss of 3 degrees, the proportions of the infused solutions and blood should be 1: 1 or 1: 2. The volume of infusions must be accurately calculated, since excessive administration of drugs can provoke a relapse of bleeding. The total dose of infusion solutions should exceed the amount of lost blood by about 200-250%.

With bleeding of 1 severity, there is no need for surgical intervention.

With bleeding of 2 severity, conservative treatment is carried out, and if it was possible to stop it, there is no need for surgery.

Surgery

With bleeding of 3 degrees of severity, profuse and recurrent, surgical treatment is often the only possible way to save the patient. Emergency surgery is necessary in case of perforation of the ulcer and the inability to stop bleeding by conservative (endoscopic and other) methods. The operation must be performed in the early stages of bleeding, since with later interventions the prognosis sharply worsens.

With bleeding ulcers of the stomach and duodenum, a stem vagotomy is performed with partial resection of the stomach, gastrotomy with excision of the ulcer or suturing of damaged vessels. The possibility of death after surgery is 5-15%. In Mallory-Weiss syndrome, a tamponade is applied using a Blackmore probe. If it is ineffective, the mucous membrane is sutured at the rupture site.

In 90% of cases, HCC can be stopped using conservative methods.

Diet for gastric bleeding

Eating is allowed only one to two days after the cessation of severe gastrointestinal bleeding. Dishes should be chilled and have a liquid or semi-liquid appearance: pureed soups, mashed potatoes, cereals, yoghurts, jelly, jelly.

As the condition improves, the diet expands: meat soufflé, soft-boiled eggs, scrambled eggs, boiled vegetables, steamed fish, baked apples are gradually added to it. Frozen cream, milk, butter are recommended.

When the patient's condition stabilizes (about 5-6 days), food is taken every two hours. The daily food volume should not exceed 400 ml.

To reduce hemorrhagic syndrome, you should eat foods rich in vitamins C, P (fruit and vegetable juices, rosehip decoction) and K (butter, cream, sour cream). Animal fats increase blood clotting and promote more rapid clot formation in peptic ulcer disease.

The author of the article: Gorshenina Elena Ivanovna | Gastroenterologist

Education: Diploma in the specialty "General Medicine" received at the Russian State Medical University named after N. I. Pirogova (2005). Postgraduate studies in the specialty "Gastroenterology" - educational and scientific medical center.