Location of the gastrointestinal tract. Image from the National Institutes of Health

Bleeding in the digestive tract is a symptom of a disease rather than a disease itself. Bleeding can occur as the result of a number of different conditions, some of which are life threatening. Most causes of bleeding are related to conditions that can be cured or controlled, such as ulcers or hemorrhoids. The cause of bleeding may not be serious, but locating the source of bleeding is important.

The digestive or gastrointestinal (GI) tract includes the esophagus, stomach, small intestine, large intestine or colon, rectum, and anus. Bleeding can come from one or more of these areas, that is, from a small area such as an ulcer on the lining of the stomach or from a large surface such as an inflammation of the colon. Bleeding can sometimes occur without the person noticing it. This type of bleeding is called occult or hidden. Fortunately, simple tests can detect occult blood in the stool.

What are the common causes of GI bleeding?

	In the esophagus:
	• inflammation (esophagitis) • enlarged veins (varices) • tear (Mallory-Weiss syndrome) • cancer
	In the stomach:
	• ulcers • inflammation (gastritis) • cancer
	In the small intestine:
	• duodenal ulcer • inflammation (inflammatory bowel disease)
	In the large intestine (colon) and rectum:
	• hemorrhoids • infections • inflammation (ulcerative colitis) • colorectal polyps • colorectal cancer • diverticular disease

What are symptoms of GI bleeding?
The signs of bleeding in the digestive tract depend upon the site and severity of bleeding. If blood is coming from the rectum or the lower colon, bright red blood will coat or mix with the stool. The stool may be mixed with darker blood if the bleeding is higher up in the colon or at the far end of the small intestine. When there is bleeding in the esophagus, stomach, or duodenum, the stool is usually black or tarry. Vomited material may be bright red or have a coffee-grounds appearance when one is bleeding from those sites. If bleeding is occult, the patient might not notice any changes in stool color.

If sudden massive bleeding occurs, a person may feel weak, dizzy, faint, short of breath, or have crampy abdominal pain or diarrhea. Shock may occur, with a rapid pulse, drop in blood pressure, and difficulty in producing urine. The patient may become very pale. If bleeding is slow and occurs over a long period of time, a gradual onset of fatigue, lethargy, shortness of breath, and pallor from the anemia will result. Anemia is a condition in which the blood's iron-rich substance, hemoglobin, is diminished.

	How do you recognize blood in the stool and vomit?
	• bright red blood coating the stool • dark blood mixed with the stool • black or tarry stool • bright red blood in vomit • coffee-grounds appearance of vomit
	What are the symptoms of acute bleeding?
	• any of bleeding symptoms above • weakness • shortness of breath • dizziness • crampy abdominal pain • faintness • diarrhea
	What are the symptoms of chronic bleeding?
	• any of bleeding symptoms above • weakness • fatigue • shortness of breath • lethargy • faintness

How can it be diagnosed?
The site of the bleeding must be located. A complete history and physical examination are essential. Symptoms such as changes in bowel habits, stool color (to black or red) and consistency, and the presence of pain or tenderness may tell the doctor which area of the GI tract is affected. Because the intake of iron, bismuth (Pepto Bismol), or foods such as beets can give the stool the same appearance as bleeding from the digestive tract, a doctor must test the stool for blood before offering a diagnosis. A blood count will indicate whether the patient is anemic and also will give an idea of the extent of the bleeding and how chronic it may be.

Endoscopy
Endoscopy is a common diagnostic technique that allows direct viewing of the bleeding site. Because the endoscope can detect lesions and confirm the presence or absence of bleeding, doctors often choose this method to diagnose patients with acute bleeding. In many cases, the doctor can use the endoscope to treat the cause of bleeding as well.

The endoscope is a flexible instrument that can be inserted through the mouth or rectum. The instrument allows the doctor to see into the esophagus, stomach, duodenum (esophago-duodenoscopy), colon (colonoscopy), and rectum (sigmoidoscopy); to collect small samples of tissue (biopsies); to take photographs; and to stop the bleeding.

Small bowel endoscopy, or enteroscopy, is a procedure using a long endoscope. This endoscope may be used to localize unidentified sources of bleeding in the small intestine.

Other procedures
Several other methods are available to locate the source of bleeding. Barium x-rays, in general, are less accurate than endoscopy in locating bleeding sites. Some drawbacks of barium x-rays are that they may interfere with other diagnostic techniques if used for detecting acute bleeding, they expose the patient to x-rays, and they do not offer the capabilities of biopsy or treatment.

Angiography is a technique that uses dye to highlight blood vessels. This procedure is most useful in situations when the patient is acutely bleeding such that dye leaks out of the blood vessel and identifies the site of bleeding. In selected situations, angiography allows injection of medicine into arteries that may stop the bleeding.

Radionuclide scanning is a noninvasive screening technique used for locating sites of acute bleeding, especially in the lower GI tract. This technique involves injection of small amounts of radioactive material. Then, a special camera produces pictures of organs, allowing the doctor to detect a bleeding site.

In addition, barium x-rays, angiography, and radionuclide scans can be used to locate sources of chronic occult bleeding. These techniques are especially useful when the small intestine is suspected as the site of bleeding since the small intestine may not be seen easily with endoscopy.

How can it be treated?
Endoscopy is the primary diagnostic and therapeutic procedure for most causes of GI bleeding.

Active bleeding from the upper GI tract can often be controlled by injecting chemicals directly into a bleeding site with a needle introduced through the endoscope. A physician can also cauterize, or heat treat, a bleeding site and surrounding tissue with a heater probe or electrocoagulation device passed through the endoscope. Laser therapy is useful in certain specialized situations.

Once bleeding is controlled, medicines are often prescribed to prevent recurrence of bleeding. Medicines are useful primarily for H. pylori, esophagitis, ulcer, infections, and inflammatory bowel disease. Medical treatment of ulcers, including the elimination of H. pylori, to ensure healing and maintenance therapy to prevent ulcer recurrence can also lessen the chance of recurrent bleeding.

Removal of polyps with an endoscope can control bleeding from colon polyps. Removal of hemorrhoids by banding or various heat or electrical devices is effective in patients who suffer hemorrhoidal bleeding on a recurrent basis. Endoscopic injection or cautery can be used to treat bleeding sites throughout the lower intestinal tract.

Endoscopic techniques do not always control bleeding. Sometimes angiography may be used. However, surgery is often needed to control active, severe, or recurrent bleeding when endoscopy is not successful.

If you have any questions or wish to schedule an appointment, please do not hesitate to call the office at (706) 548-0058. Remember that we usually require that you see a primary care physician (your family doctor or PCP) before we can schedule you. If you are having a medical emergency, get medical attention immediately at your nearest healthcare provider:

Athens Regional Medical Center: (706) 475-7000
St. Mary's Hospital: (706) 354-3000

This informational material from the National Digestive Diseases Information Clearinghouse, a division of the U.S. Department of Health and Human Resources.

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