Gastro-intestinal Haemorrhage

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Gastro-intestinal haemorrhage, commonly referred to as GI bleeding, is a medical condition characterised by the abnormal bleeding within the digestive system. It occurs when blood is discharged from any part of the digestive tract, which includes the oesophagus, stomach, small intestine, large intestine (colon), rectum, or anus.

1. Peptic Ulcers: Open sores or ulcers that develop on the lining of the stomach or upper portion of the small intestine can cause bleeding.
2. Gastritis: Inflammation of the stomach lining, often caused by excessive alcohol consumption, certain medications, or bacterial infections like Helicobacter pylori, can lead to GI bleeding.
3. Oesophageal Varices: These are enlarged and swollen blood vessels in the oesophagus that commonly occur in people with advanced liver cirrhosis. These fragile blood vessels can rupture and cause severe bleeding.
4. Colorectal Polyps or Cancer: When growths (polyps) or cancerous tumours develop in the colon or rectum, they can bleed and cause GI bleeding.
5. Diverticulosis: The presence of small bulges or pouches (diverticula) within the wall of the large intestine can occasionally bleed.
6. Haemorrhoids: Swollen and inflamed blood vessels in the rectum and anus can bleed, leading to blood in the stool.
7. Mallory-Weiss Syndrome: Severe vomiting or retching can result in tears in the lining of the oesophagus, causing GI bleeding.

1. Upper Gastrointestinal Bleeding (UGIB):

• Ulcers: Peptic ulcers, either gastric or duodenal, are a significant cause of UGIB. These ulcers develop due to an imbalance between aggressive factors (acid, pepsin, helicobacter pylori infection) and defensive mechanisms (mucus, bicarbonate). When ulcers erode into blood vessels, bleeding occurs.

• Varices: In cases of chronic liver disease, such as cirrhosis, the increased pressure in the portal vein leads to collateral blood vessel formation in the oesophagus (oesophageal varices) or stomach (gastric varices). These dilated vessels are prone to rupture, resulting in severe bleeding.

• Mallory-Weiss Tears: These tears typically occur as a result of severe vomiting or retching, which exerts excessive force on the gastroesophageal junction. The mucosal tear that forms can cause bleeding.

2. Lower Gastrointestinal Bleeding (LGIB):

• Diverticulosis: Diverticula are outpouchings that develop in the walls of the colon due to increased intraluminal pressure. When these diverticula become inflamed or ruptured, they can lead to significant bleeding.

• Colorectal Cancer: When cancerous growths develop in the colon or rectum, they can ulcerate, erode blood vessels, and result in bleeding.

1. Age:
Advancing age is a significant risk factor for gastrointestinal haemorrhage. As people grow older, they become more susceptible to conditions that can cause GI bleeding, such as peptic ulcers, diverticulosis, and gastrointestinal malignancies. Age-related changes in blood vessels and diminished tissue integrity also contribute to an increased risk.
2. Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):
Frequent and long-term use of non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin, ibuprofen, and naproxen, can significantly elevate the risk of gastrointestinal bleeding. These medications, commonly used for pain relief and managing inflammatory conditions, can irritate the lining of the stomach and small intestine, leading to ulcers and subsequent bleeding.
3. Alcohol and Drug Abuse:
Excessive alcohol consumption and drug abuse, particularly cocaine or heroin, can contribute to gastrointestinal haemorrhage. Alcohol and drugs disrupt the integrity of the gastrointestinal lining, increase blood pressure, and interfere with blood clotting mechanisms, making individuals more prone to bleeding.
4. Helicobacter pylori (H. pylori) Infection:
H. pylori is a bacterium that colonises the lining of the stomach and is associated with the development of gastric ulcers. Chronic infection with this bacterium can weaken the stomach lining and increase the risk of bleeding. Timely detection and treatment are crucial in eradicating H. pylori, effectively reducing the risk of GI haemorrhage.
5. Chronic Liver Disease:
Patients with chronic liver diseases such as cirrhosis and hepatitis are at a higher risk of gastrointestinal haemorrhage. Portal hypertension resulting from liver disease causes an increased pressure in the veins that supply blood to the liver and the digestive tract. Over time, this elevated pressure can lead to varices—abnormally enlarged blood vessels—that are prone to rupture, causing severe bleeding.
6. Inflammatory Bowel Disease (IBD):
Inflammatory bowel diseases, including Crohn's disease and ulcerative colitis, significantly increase the risk of gastrointestinal haemorrhage. These chronic conditions cause inflammation and ulceration within the gastrointestinal tract, making the affected areas susceptible to bleeding.
7. Blood Disorders and Coagulopathies:
Certain blood disorders and coagulopathies that impair blood clotting mechanisms increase the risk of gastrointestinal bleeding. These conditions can be genetic, such as haemophilia or von Willebrand disease, or acquired, such as liver disease-associated coagulopathy or drug-induced coagulation abnormalities. When necessary.

1. Vomiting Blood: Sometimes, fresh blood or coffee-ground-like material may be present in vomit.
2. Bright Red or Dark Black Stool: Blood in the stool can appear as bright red or dark black, depending on the site and rate of bleeding.
3. Abdominal Pain or Cramping: Persistent or severe abdominal pain, especially when accompanied by bleeding, can indicate GI bleeding.
4. Weakness and Fatigue: Experiencing weakness, dizziness, lightheadedness, or fatigue due to significant blood loss may occur.
5. Shortness of Breath: If blood loss is significant, it can lead to a decrease in the oxygen-carrying capability of blood, resulting in shortness of breath.
6. Faintness or Syncope: In extreme cases, the loss of a substantial amount of blood may cause fainting or syncope.

1. History and Physical Examination.
2. Blood Tests:
These may include full blood count (FBC), coagulation profile, liver function tests, and renal profile. These investigations aid in identifying any underlying conditions, anaemia, or clotting disorders that could be responsible for the bleeding.
3. Endoscopy:
Endoscopy is a fundamental diagnostic procedure employed in the evaluation of gastrointestinal bleeding. Upper endoscopy and colonoscopy are two commonly used methods. A flexible tube with a camera is passed through the mouth, oesophagus, and stomach to examine the upper digestive tract for any potential sources of bleeding. Similarly, colonoscopy allows visualisation of the large intestine to detect the site of bleeding.
4. Radiographic Studies:
Radiographic investigations, such as a chest x-ray and abdominal ultrasound, may be conducted to identify any signs of gastrointestinal haemorrhage. X-rays can reveal air in the gastrointestinal tract, which may indicate the presence of an actively bleeding lesion. Ultrasound can detect abnormalities in the abdominal organs and help locate the source of bleeding or assess blood flow to the affected area.
5. Other Investigations:
These can include computed tomography (CT) scans, magnetic resonance imaging (MRI), nuclear medicine scans, or endoscopy.

• Surgical Interventions: Once the bleeding source is identified, appropriate medical or surgical interventions can be implemented to manage gastro-intestinal haemorrhage, such as IV access, blood transfusion, clotting measurements, catheterisation etc.

• Ongoing management: Proton pump inhibitors or H2 receptor antagonists can be employed to reduce gastric acid secretion and promote healing of ulcers or erosions. If the patient is taking anticoagulant medications, their usage should be carefully evaluated and temporarily discontinued if possible.

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