GASTROINTESTINAL BLEEDING

Definitions

1. Hematemesis

2. Refers to emesis of fresh blood (bright red) or old blood (“coffee grounds”; more than 2–3 minutes in gastric contents). It should be distinguished from nasal bleeding and hemoptysis, either of which may be swallowed and vomited or directly spat out. When the source of bleeding is in the Gl tract, it is usually from a site proximal to the ligament of Treitz.

3. Hematochezia

4. Refers to the passage of fresh blood per rectum. The source of bleeding is usually in the colon although a large volume upper gastrointestinal (Gl) bleed with rapid intestinal transit may present as hematochezia. In these circumstances, the blood may be bright red or slightly maroon.

5. Melena

6. Refers to the passage of shiny, black, tarry stools which are strongly positive on guaiac testing (Hemoccult).

Etiology

Table I classifies the causes of Gl bleeding by age group and site of bleeding. There are several conditions that can mimic Gl bleeding and they should be excluded:

• Swallowed blood from nasopharynx or lungs.

• Red colored candies, juices and foods.

• Black colored (Hemoccult negative) stools: Bismuth (Pepto–Bismol), iron preparations, licorice and blueberries.

• Normal color stools, false positive Hemoccult: spinach, meat fibers.

In some conditions, bleeding can be slow or “occult” with no overt bleeding episode. This may present as iron deficiency anemia.

Causes of occult Gl bleeding (many of these disorders also cause overt Gl bleeding):

• Inflammatory causes: duodenal ulcer, peptic esophagitis, gastric ulcer, Crohn's disease, ulcerative colitis, eosinophilic gastroenteritis.

• Infectious causes: H. pylori duodenal ulcer, H. pylori gastric ulcer, hookworm, strongyloidiasis, ascariasis, tuberculous enterocolitis, amebiasis.