Definitions
GI bleeding is any blood loss from the GI tract (anywhere from the mouth to the anus), which may present with haematemesis, melaena, rectal bleeding or anaemia. Haematemesis is defined as vomiting blood and is usually caused by upper GI disease. Melaena is the passage PR of a black treacle-like stool that contains altered blood, usually as a result of proximal bowel bleeding. Haematochesia is the presence of undigested blood in the stool usually from lower GI causes.
Upper GI Bleeding
Key Points
- Haematemesis is usually caused by lesions proximal to the duodeno-jejunal junction.
- Melaena may be caused by lesions anywhere from oesophagus to colon.
- Haematochesia is usually caused by lower GI pathology (colorectal tumours, haemorrhoids, diverticulitis, angiodysplasia), brisk acute upper GI bleeding may also present in this way.
- Most tumours more commonly cause anaemia than frank haematemesis.
- In young adults, PUD, congenital lesions and varices are common causes.
- In the elderly, tumours, PUD and angiodysplasia are common causes.
Important Diagnostic Features
Oesophagus
- Reflux oesophagitis: small volumes, bright red, associated with regurgitation.
- Oesophageal carcinoma: scanty, blood-stained debris, rarely significant volume, associated with weight loss, anergia, dysphagia.
- Bleeding varices (oesophageal or gastric): sudden onset, painless, large volumes, dark or bright red blood, history of (alcoholic) liver disease, other features of portal hypertension (ascites, dilated abdominal veins, encephalopathy, reduced platelets or white cells).
- Trauma during vomiting (Mallory–Weiss syndrome): bright red bloody vomit usually preceded by several normal but forceful vomiting episodes.
Stomach
- Erosive gastritis: small volumes, bright red, may follow alcohol or NSAID intake, history of dyspepsia.
- Gastric ulcer: often larger sized bleed, painless, possible preceding (herald) smaller bleeds, accompanied by altered blood (‘coffee grounds’), history of PUD.
- Gastric cancer: rarely large bleed, anaemia more common, associated weight loss, anorexia, dyspeptic symptoms.
- Gastric leiomyoma (rare): spontaneous-onset moderate-sized bleed.
- Dieulafoy’s disease (rare): younger patients, spontaneous large bleed, difficult to diagnose.
Duodenum
- Duodenitis: small volumes, bright red, may follow alcohol or NSAID use, history of dyspepsia.
- Duodenal ulcer: past history of duodenal ulcer, melaena often also prominent, symptoms of back pain, hunger pains, NSAID use.
- Aortoduodenal fistula (rare): usually infected graft post AAA repair, massive haematemesis and PR bleed, usually fatal.
