Gastrointestinal Bleeding — Diagnosis and Endoscopic Hemostasis

What Is Gastrointestinal Bleeding?

Gastrointestinal (GI) bleeding refers to any bleeding that originates within the digestive tract, from the esophagus to the rectum. It is a common medical emergency that ranges from mild, self-limiting episodes to massive, life-threatening hemorrhage. GI bleeding is broadly classified based on its origin relative to the ligament of Treitz (a landmark at the junction of the duodenum and jejunum).

Upper GI Bleeding

Bleeding originating from the esophagus, stomach, or duodenum (above the ligament of Treitz). This accounts for the majority of acute GI bleeding cases and is often more severe.

Lower GI Bleeding

Bleeding originating from the jejunum, ileum, colon, or rectum (below the ligament of Treitz). Lower GI bleeding is more common in older adults and is often less severe than upper GI bleeding.

Causes

Upper GI Bleeding

• Peptic ulcers — gastric and duodenal ulcers are the most common cause, often related to Helicobacter pylori infection or nonsteroidal anti-inflammatory drug (NSAID) use
• Esophageal varices — dilated veins in the esophagus due to portal hypertension in cirrhosis (esophageal varices)
• Mallory-Weiss tear — a mucosal tear at the gastroesophageal junction, often caused by forceful vomiting
• Erosive esophagitis or gastritis
• Dieulafoy lesion — a large submucosal artery that erodes through the mucosa
• Upper GI tumors — gastric cancer, esophageal cancer
• Angiodysplasia — vascular malformations

Lower GI Bleeding

• Diverticular disease — the most common cause of acute lower GI bleeding in adults
• Angiodysplasia — arteriovenous malformations, more common in the right colon
• Colorectal polyps and cancer
• Inflammatory bowel disease — ulcerative colitis, Crohn's disease
• Hemorrhoids — the most common cause of minor rectal bleeding
• Ischemic colitis
• Post-polypectomy bleeding

Warning Signs

Recognizing the signs of GI bleeding is crucial for timely treatment:

• Hematemesis — vomiting of blood. Fresh red blood indicates active upper GI bleeding; "coffee-ground" vomit suggests older, partially digested blood.
• Melena — black, tarry, foul-smelling stools. Indicates upper GI bleeding (or proximal small bowel) where blood has been partially digested.
• Hematochezia — passage of fresh red blood from the rectum. Usually indicates lower GI bleeding, but can occur with massive upper GI bleeding.
• Occult bleeding — not visible to the eye, detected by fecal occult blood testing. May present as iron deficiency anemia.
• Signs of significant blood loss — lightheadedness, dizziness, fainting, rapid heartbeat, pallor, low blood pressure, and shortness of breath.

Emergency Endoscopy

Endoscopy is the cornerstone of both diagnosis and treatment of GI bleeding. Diagnostic and therapeutic endoscopy allows direct visualization of the bleeding source and immediate intervention:

• Upper endoscopy (EGD) — performed urgently (within 24 hours, or within 12 hours for high-risk bleeding) to identify and treat upper GI bleeding sources
• Colonoscopy — performed after adequate bowel preparation to evaluate lower GI bleeding
• Capsule endoscopy and deep enteroscopy — for obscure bleeding originating from the small bowel

Endoscopic Hemostasis Techniques

Modern therapeutic endoscopy offers multiple effective methods to stop GI bleeding:

• Injection therapy — diluted epinephrine is injected around the bleeding site to achieve initial hemostasis through vasoconstriction and tamponade. Always combined with a second modality.
• Hemostatic clips — mechanical clips are applied directly to the bleeding vessel, providing definitive hemostasis. Through-the-scope clips and over-the-scope clips (OTSC) are available for different lesion types.
• Thermal coagulation — bipolar electrocoagulation, heater probe, or argon plasma coagulation (APC) is used to cauterize the bleeding site
• Endoscopic band ligation (EVL) — the primary technique for bleeding esophageal varices, where small rubber bands are placed around the varices to occlude them
• Hemostatic powders — topical hemostatic agents (TC-325/Hemospray) sprayed directly onto diffuse bleeding sites

Recovery

After successful endoscopic hemostasis:

• Patients are monitored in the hospital for signs of re-bleeding (typically 24-72 hours)
• Acid-suppressing medication (high-dose proton pump inhibitors) is administered intravenously for peptic ulcer bleeding
• Blood transfusions may be needed to correct anemia
• Identification and treatment of the underlying cause (H. pylori eradication, NSAID discontinuation, variceal prophylaxis)
• Iron supplementation may be required for weeks to months
• Dietary progression from clear liquids to normal diet as tolerated

When to Seek Emergency Care IMMEDIATELY

GI bleeding is a medical emergency. Call emergency services or go to the nearest emergency department immediately if you experience:

• Vomiting blood or material that looks like coffee grounds
• Black, tarry stools (melena)
• Large amounts of bright red blood from the rectum
• Feeling faint, dizzy, or losing consciousness
• Rapid heartbeat, cold sweaty skin, confusion
• Severe abdominal pain accompanied by any bleeding signs

Do not wait to see if the bleeding stops on its own. Significant GI bleeding can cause life-threatening blood loss within a short time. Early endoscopic intervention saves lives.