Bleeding may occur anywhere along the digestive (gastrointestinal [GI]) tract, from the mouth to the anus. Blood may be easily seen by the naked eye (overt), or blood may be present in amounts too small to be visible (occult). Occult bleeding is detected only by testing a stool specimen with special chemicals Stool Occult Blood Tests Bleeding in the digestive system can be caused by something as insignificant as a little irritation or as serious as cancer. Chemicals can be used to detect small amounts of blood in the stool... read more .
Hematemesis is blood that is visible in vomit (hematemesis), which indicates the bleeding is coming from the upper GI tract, usually from the esophagus, stomach, or the first part of the small intestine. When blood is vomited, it may be bright red if bleeding is brisk and ongoing. Alternatively, vomited blood may have the appearance of coffee grounds. It results from bleeding that has slowed or stopped, and the blood looks like coffee grounds because it has been partially digested by acid in the stomach.
Blood may also be passed from the rectum:
As black, tarry stools (melena)
As bright red blood (hematochezia)
In apparently normal stool if bleeding is less than a few teaspoons per day
Melena is more likely when bleeding comes from the esophagus, stomach, or small intestine. The black color of melena is caused by blood that has been exposed for several hours to stomach acid and enzymes and to bacteria that normally reside in the large intestine. Melena may continue for several days after bleeding has stopped.
Hematochezia is more likely when bleeding comes from the large intestine, although it can be caused by very rapid bleeding from the upper portions of the digestive tract as well.
People who have lost only a small amount of blood may feel well otherwise. However, serious and sudden blood loss may be accompanied by a rapid pulse, low blood pressure, and reduced urine flow. A person may also have cold, clammy hands and feet. Severe bleeding may reduce the flow of blood to the brain, causing confusion, disorientation, sleepiness, and even extremely low blood pressure (shock Shock Shock is a life-threatening condition in which blood flow to the organs is low, decreasing delivery of oxygen and thus causing organ damage and sometimes death. Blood pressure is usually low... read more ). Slow, chronic blood loss may cause symptoms and signs of low blood count (anemia Overview of Anemia Anemia is a condition in which the number of red blood cells is low. Red blood cells contain hemoglobin, a protein that enables them to carry oxygen from the lungs and deliver it to all parts... read more ), such as weakness, easy fatigue, paleness (pallor), chest pain, and dizziness. People with underlying ischemic heart disease may develop chest pain (angina) or a have a heart attack (myocardial infarction) because of decreased blood flow through the heart.
(See also Overview of Digestive Symptoms Overview of Digestive Symptoms Disorders that affect the digestive (gastrointestinal) system are called digestive disorders. Some disorders simultaneously affect several parts of the digestive system, whereas others affect... read more .)
Causes of Gastrointestinal Bleeding
The causes of GI bleeding are divided into three areas:
Upper GI tract
Lower GI tract
The most common causes are difficult to specify because causes vary by the area that is bleeding and the person's age.
However, in general, the most common causes of upper GI bleeding are
A tear in the lining of the esophagus after vomiting (Mallory-Weiss syndrome Esophageal Laceration (Mallory-Weiss Syndrome) An esophageal laceration (Mallory-Weiss syndrome) is a tear that does not penetrate the wall of the esophagus. The tear can be caused by forceful vomiting. Symptoms include blood in vomit. The... read more )
The most common causes of lower GI bleeding are
Abnormal blood vessels (angiodysplasia, arteriovenous malformations [AVMs])
Other causes of lower GI bleeding include abnormal blood vessels in the colon, a split in the skin of the anus (anal fissure Anal Fissure An anal fissure is a tear or ulcer in the lining of the anus (the opening at the end of the digestive tract where stool leaves the body). Anal fissures may occur after passage of hard or large... read more ), ischemic colitis Ischemic Colitis Ischemic colitis is injury of the large intestine that results from an interruption of blood flow. Abdominal pain and bloody stools are common. Computed tomography is usually done, and colonoscopy... read more , and large bowel inflammation resulting from radiation or poor blood supply.
Bleeding from the small intestine is rare but can result from blood vessel abnormalities, tumors, or a Meckel diverticulum Meckel Diverticulum A Meckel diverticulum is a saclike outpouching of the wall of the small intestine that is present in some children at birth. Most children do not have symptoms, but sometimes painless rectal... read more .
Bleeding from any cause is more likely, and potentially more severe, in people who have chronic liver disease Overview of Liver Disease Liver disease can manifest in many different ways. Characteristic manifestations include Jaundice (a yellowish discoloration of the skin and whites of the eyes) Cholestasis (reduction or stoppage... read more (caused by an alcohol use disorder or chronic hepatitis), who have hereditary disorders of blood clotting Uncommon Inherited Clotting Disorders Hemophilia is the most common hereditary clotting disorder (see also Overview of Blood Clotting Disorders). Hemophilia involves an inherited deficiency of certain clotting factors (proteins... read more , or who are taking certain drugs. Liver disease makes bleeding more likely because a poorly functioning liver produces fewer of the proteins that help blood clot (blood clotting factors Blood clotting factors Hemostasis is the body's way of stopping injured blood vessels from bleeding. Hemostasis includes clotting of the blood. Too little clotting can cause excessive bleeding from minor injury Too... read more ). Drugs that can cause or worsen bleeding include anticoagulants (such as heparin, warfarin, dabigatran, apixaban, rivaroxaban, and edoxaban), those that affect platelet function (such as aspirin and certain other nonsteroidal anti-inflammatory drugs [NSAIDs] and clopidogrel), and those that affect the stomach's protective barrier against acid (such as NSAIDs).
Evaluation of Gastrointestinal Bleeding
GI bleeding typically requires evaluation by a doctor. The following information can help people decide when a doctor’s evaluation is needed and help them know what to expect during the evaluation.
In people with GI bleeding, certain symptoms and characteristics are cause for concern. They include
Rapid heart rate (over 100 beats per minute)
Passing more than 1 cup (250 milliliters) of blood
When to see a doctor
People who have GI bleeding should see a doctor right away unless the only sign of bleeding is blood on the toilet paper after a bowel movement. If people with such findings have no warning signs and feel otherwise well, a delay of a day or two is not harmful.
What the doctor does
Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the GI bleeding and the tests that may need to be done ( see Table: Some Causes and Features of Gastrointestinal Bleeding Some Causes and Features of Gastrointestinal Bleeding ).
The history is focused on finding out exactly where the bleeding is coming from, how rapid it is, and what is causing it. Doctors need to know how much blood (for instance, a few teaspoons or several clots) is being passed and how often blood is being passed. People with hematemesis are asked whether blood was passed the first time they vomited or only after they vomited a few times with no blood.
Doctors ask people with rectal bleeding whether pure blood was passed; whether it was mixed with stool, pus, or mucus; or whether blood simply coated the stool. People with bloody diarrhea are asked about recent travel or other possible forms of exposure to other agents that can cause digestive tract illness (for instance, food poisoning).
Doctors then ask about symptoms of abdominal discomfort, weight loss, and easy bleeding or bruising and symptoms of anemia (such as weakness, easy exhaustion [fatigability], and dizziness).
Doctors need to know about any current or past digestive tract bleeding and the results of any previous colonoscopy (examination of the entire large intestine, the rectum, and the anus using a flexible viewing tube). People should tell doctors whether they have inflammatory bowel disease Overview of Inflammatory Bowel Disease (IBD) In inflammatory bowel diseases, the intestine (bowel) becomes inflamed, often causing recurring abdominal pain and diarrhea. The two primary types of inflammatory bowel disease (IBD) are Crohn... read more , bleeding tendencies, or liver disease and whether they use any drugs that increase the likelihood of bleeding (such as aspirin, NSAIDs, or anticoagulants) or can cause chronic liver disease (such as alcohol).
The physical examination is focused on the person’s vital signs (such as pulse, breathing rate, blood pressure, and temperature) and other indicators of shock or a decrease in the volume of circulating blood (hypovolemia—rapid heart rate, rapid breathing, pallor, sweating, little urine production, and confusion) and anemia.
Doctors also look for small purplish red (petechiae) and bruise-like (ecchymoses) spots on the skin, which are signs of bleeding disorders. Doctors also look for signs of chronic liver disease (such as spider angiomas, fluid in the abdominal cavity [ ascites Ascites Ascites is the accumulation of protein-containing (ascitic) fluid within the abdomen. Many disorders can cause ascites, but the most common is high blood pressure in the veins that bring blood... read more ], and red palms) and portal hypertension Portal Hypertension Portal hypertension is abnormally high blood pressure in the portal vein (the large vein that brings blood from the intestine to the liver) and its branches. Cirrhosis (scarring that distorts... read more (such as an enlarged spleen and dilated abdominal wall veins).
Doctors do a rectal examination to look at stool color and check it for blood and to search for tumors and fissures Anal Fissure An anal fissure is a tear or ulcer in the lining of the anus (the opening at the end of the digestive tract where stool leaves the body). Anal fissures may occur after passage of hard or large... read more . Doctors also examine the anus to look for hemorrhoids Hemorrhoids Hemorrhoids are dilated, twisted blood vessels located in the wall of the lower rectum and anus. The swollen vessels are caused by an increase in pressure. Lumps form inside or outside of the... read more .
The need for tests depends on what doctors find during the history and physical examination, particularly whether warning signs are present.
There are four main testing approaches to GI bleeding:
Blood tests and other laboratory studies
Upper endoscopy for suspected upper GI tract bleeding
Colonoscopy for lower GI tract bleeding (unless clearly caused by hemorrhoids)
Angiography if bleeding is rapid or severe
The person’s blood count helps indicate how much blood has been lost. A low platelet count is a risk factor for bleeding. Other blood tests include prothrombin time (PT), partial thromboplastin time (PTT), and liver tests, all of which help detect problems with blood clotting. Doctors often do not do blood tests on people who have minor bleeding caused by hemorrhoids.
If the person has vomited blood or dark material (which may represent partially digested blood), the doctor sometimes passes a small, hollow plastic tube through the person’s nose down into the stomach (nasogastric tube— see Intubation of the Digestive Tract Intubation of the Digestive Tract Intubation of the digestive tract is the process of passing a small, flexible plastic tube (nasogastric tube) through the nose or mouth into the stomach or small intestine. This procedure may... read more ) and suctions out the stomach contents. Bloody or pink contents indicate active upper GI bleeding, and dark or coffee-ground material indicates that bleeding is slow or has stopped. Sometimes, there is no sign of blood even though the person was bleeding very recently. A nasogastric tube may be inserted in anyone who has not vomited but has passed a large amount of blood from the rectum (if not from an obvious hemorrhoid) because this blood may have originated in the upper digestive tract.
If the nasogastric tube reveals signs of active bleeding, or the person’s symptoms strongly suggest the bleeding is originating in the upper digestive tract, the doctor usually does upper endoscopy. Upper endoscopy Endoscopy Endoscopy is an examination of internal structures using a flexible viewing tube (endoscope). Endoscopy can also be used to treat many disorders because doctors are able to pass instruments... read more is a visual examination of the esophagus, stomach, and the first segment of the small intestine (duodenum) using a flexible tube called an endoscope. An upper endoscopy allows the doctor to see the bleeding source and often treat it and is often done without a nasogastric tube being passed.
People with symptoms typical of hemorrhoids may need only sigmoidoscopy (examination of the lower part of the large intestine, the rectum, and anus using an endoscope). All other people with hematochezia should have colonoscopy (examination of the entire large intestine, the rectum, and the anus using an endoscope).
Occasionally, endoscopy (both upper and lower) and colonoscopy do not show the cause of bleeding. There are still other options for finding the source of the bleeding. Doctors may do endoscopy of the small bowel (enteroscopy). If bleeding is rapid or severe, doctors sometimes do angiography Angiography In angiography, x-rays are used to produce detailed images of blood vessels. It is sometimes called conventional angiography to distinguish it from computed tomography (CT) angiography and magnetic... read more . During angiography, doctors use a catheter to inject an artery with a contrast agent that can be seen on x-rays. Angiography helps doctors diagnose upper digestive tract bleeding and allows them to do certain treatments (such as embolization and vasoconstrictor infusion— see Stopping the bleeding Stopping the bleeding Bleeding may occur anywhere along the digestive (gastrointestinal [GI]) tract, from the mouth to the anus. Blood may be easily seen by the naked eye (overt), or blood may be present in amounts... read more ). Doctors may also inject the person with red blood cells labeled with a radioactive marker (radionuclide scanning Radionuclide Scanning In radionuclide scanning, radionuclides are used to produce images. A radionuclide is a radioactive form of an element, which means it is an unstable atom that becomes more stable by releasing... read more ). With the use of a special scanning camera, the radioactive marker can sometimes show the approximate location of the bleeding. Before doing angiography or surgery, doctors may also do a test called CT angiography CT angiography In computed tomography (CT), which used to be called computed axial tomography (CAT), an x-ray source and x-ray detector rotate around a person. In modern scanners, the x-ray detector usually... read more . During this procedure, a type of imaging called computed tomography (CT) and a radiopaque contrast agent are used to produce images of blood vessels and sometimes can show the location of the bleeding.
Doctors may do a small-bowel follow-through, which is a series of detailed x-rays of the small intestine. Another option is video capsule endoscopy Video Capsule Endoscopy Video capsule endoscopy (wireless video endoscopy) is a procedure in which the person swallows a battery-powered capsule. The capsule contains one or two small cameras, a light, and a transmitter... read more , in which people swallow a tiny camera that takes pictures as it passes through the intestines. Video capsule endoscopy is especially useful in the small intestine, but it is not very useful in either the colon or stomach because these organs are easier to see using endoscopy.
Treatment of Gastrointestinal Bleeding
There are two goals to treating people with GI bleeding:
Replace lost blood with fluid given by vein (intravenously) and sometimes with a blood transfusion
Stop any ongoing bleeding
Hematemesis, hematochezia, or melena should be considered an emergency. People with severe GI bleeding should be admitted to an intensive care unit Types of units People who need specific types of care may be put in special care units. Intensive care units (ICUs) are for people who are seriously ill. These people include those who have had a sudden, general... read more (ICU) or other closely monitored setting and should be seen by a gastroenterologist and a surgeon.
Replacing fluids and blood
People with sudden, severe blood loss require intravenous fluids and sometimes an emergency blood transfusion Overview of Blood Transfusion A blood transfusion is the transfer of blood or a blood component from one healthy person (a donor) to a sick person (a recipient). Transfusions are given to increase the blood's ability to... read more to stabilize their condition. People with blood clotting abnormalities may require transfusion of platelets Platelets People are sometimes given transfusions of whole blood during severe bleeding (for example after an injury or pregnancy complications), but usually they are given only the blood component they... read more or fresh frozen plasma Plasma People are sometimes given transfusions of whole blood during severe bleeding (for example after an injury or pregnancy complications), but usually they are given only the blood component they... read more .
Stopping the bleeding
Most GI bleeding stops without treatment. Sometimes, however, it does not. The type and location of bleeding tells the doctors what treatment to use. For example, doctors can often stop peptic ulcer bleeding during endoscopy by using a device that uses an electrical current to produce heat (electrocautery), heater probes, or injections of certain drugs. If endoscopy does not stop the bleeding, surgery may be needed.
For esophageal varices Esophageal Varices Esophageal varices are enlarged veins in the esophagus, which can cause major bleeding. Esophageal varices are caused by high blood pressure in blood vessels in and around the liver (portal... read more (enlarged veins in the esophagus), doctors try to stop bleeding with endoscopic banding, injection sclerotherapy, placement of a tube with balloons to compress the varices, or a transjugular intrahepatic portosystemic shunting Treatment Portal hypertension is abnormally high blood pressure in the portal vein (the large vein that brings blood from the intestine to the liver) and its branches. Cirrhosis (scarring that distorts... read more procedure. People with esophageal varices may be given injections of the drug octreotide to help stop the bleeding. Antibiotics may also be given.
Doctors can sometimes control severe, ongoing lower GI bleeding caused by diverticula or angiodysplasias during colonoscopy by using clips, an electrocautery device, coagulation with a heater probe, or injection with epinephrine. Polyps can be removed by a wire snare or electrocautery. If these methods do not work or are impossible, doctors do angiography Testing during which they may pass a catheter into the bleeding vessel and then inject a chemical, fragments of a gelatin sponge, or a wire coil to block the blood vessel and thereby stop the bleeding (embolization) or inject vasopressin to reduce blood flow to the bleeding vessel. People with continued bleeding may need surgery, so it is important for doctors to know the location of the bleeding site.
Doctors may give people with upper GI bleeding a proton pump inhibitor (PPI) by vein (intravenously) to help control the bleeding.
Internal hemorrhoid bleeding stops spontaneously in most cases. For people whose bleeding does not stop without treatment, doctors do anoscopy and may place rubber bands around the hemorrhoids or inject them with substances that stop bleeding or do electrocautery or surgery (see treatment of hemorrhoids Treatment Hemorrhoids are dilated, twisted blood vessels located in the wall of the lower rectum and anus. The swollen vessels are caused by an increase in pressure. Lumps form inside or outside of the... read more ).
Essentials for Older People
In older people, hemorrhoids Hemorrhoids Hemorrhoids are dilated, twisted blood vessels located in the wall of the lower rectum and anus. The swollen vessels are caused by an increase in pressure. Lumps form inside or outside of the... read more and colorectal cancer Colorectal Cancer Family history and some dietary factors (low fiber, high fat) increase a person’s risk of colorectal cancer. Typical symptoms include bleeding during a bowel movement, fatigue, and weakness... read more are the most common causes of minor bleeding. Peptic ulcers Peptic Ulcer Disease A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices. Peptic ulcers can result from Helicobacter pylori... read more , diverticular disease Definition of Diverticular Disease Diverticular disease is characterized by small, balloon-like sacs (diverticula) protruding through the layers of particular structures in the gastrointestinal tract (digestive tract). A single... read more (such as diverticulitis), and abnormal blood vessels (angiodysplasia) are the most common causes of major bleeding. Bleeding from enlarged veins in the esophagus (esophageal varices Esophageal Varices Esophageal varices are enlarged veins in the esophagus, which can cause major bleeding. Esophageal varices are caused by high blood pressure in blood vessels in and around the liver (portal... read more ) is less common than in younger people.
Older people poorly tolerate massive GI bleeding. Doctors must diagnosis older people quickly, and treatment must be started sooner than in younger people, who can better tolerate repeated episodes of bleeding.
Key Points about Gastrointestinal Bleeding
Rectal bleeding may result from upper or lower GI bleeding.
Most people stop bleeding spontaneously.
Endoscopy is usually the first treatment choice for people whose bleeding will not stop without treatment.