Faucet vs. Com vs. Destroyable vs. Aboriginal vs. Coelomate vs. Ocean vs. Judge vs. Flag vs. Forbear vs. Awesomely vs. Fat vs. Sonhood vs. Ricochet vs. Channel vs. Trending Comparisons. Mandate vs. Ivermectin vs. Skinwalker vs. Socialism vs. Man vs. Supersonic vs. Gazelle vs. Jem vs. Arteriovenous malformations, especially of the mucous membranes, suggest hereditary hemorrhagic telangiectasia Hereditary Hemorrhagic Telangiectasia Hereditary hemorrhagic telangiectasia is a hereditary disorder of vascular malformation transmitted as an autosomal dominant trait affecting men and women.
See also Overview of Vascular Bleeding Cutaneous nail bed and GI telangiectasia may indicate systemic sclerosis Systemic Sclerosis Systemic sclerosis is a rare chronic disease of unknown cause characterized by diffuse fibrosis and vascular abnormalities in the skin, joints, and internal organs especially the esophagus CBC should be obtained in patients with large-volume or occult blood loss.
Patients with more significant bleeding also require coagulation studies eg, platelet count, prothrombin time [PT], partial thromboplastin time [PTT] and liver tests eg, bilirubin, alkaline phosphatase, albumin, aspartate aminotransferase [AST], alanine aminotransferase [ALT]. Type and cross-match are done if bleeding is ongoing. Hemoglobin and hematocrit may be repeated up to every 6 hours in patients with severe bleeding. Additionally, one or more diagnostic procedures are typically required.
Nasogastric aspiration and lavage should be done in all patients with suspected upper GI bleeding eg, hematemesis, coffee-ground emesis, melena, massive rectal bleeding. Coffee-ground material indicates bleeding that is slow or stopped. If there is no sign of bleeding, and bile is returned, the NGT is removed; otherwise, it is left in place to monitor continuing or recurrent bleeding.
Nonbloody, nonbilious return is considered a nondiagnostic aspirate. Upper endoscopy examination of the esophagus, stomach, and duodenum should be done for upper GI bleeding. Because endoscopy may be therapeutic as well as diagnostic, it should be done rapidly for significant bleeding but may be deferred for 24 hours if bleeding stops or is minimal. Upper GI barium x-rays have no role in acute bleeding, and the contrast used may obscure subsequent attempts at angiography.
Angiography is useful in the diagnosis of upper GI bleeding and permits certain therapeutic maneuvers eg, embolization, vasoconstrictor infusion. Flexible sigmoidoscopy and anoscopy may be all that is required acutely for patients with symptoms typical of hemorrhoidal bleeding.
All other patients with hematochezia should have colonoscopy , which can be done electively after routine preparation unless there is significant ongoing bleeding. In such patients, a rapid prep 5 to 6 L of polyethylene glycol solution delivered via NGT or by mouth over 3 to 4 hours often allows adequate visualization. Some angiographers first take a radionuclide scan to focus the examination, because angiography is less sensitive than the radionuclide scan.
Diagnosis of occult bleeding can be difficult, because heme-positive stools may result from bleeding anywhere in the GI tract. Endoscopy is the preferred method, with symptoms determining whether the upper or lower GI tract is examined first.
Double-contrast barium enema and sigmoidoscopy can be used for the lower tract when colonoscopy is unavailable or the patient refuses it. If the results of upper endoscopy and colonoscopy are negative and occult blood persists in the stool, an upper GI series with small-bowel follow-through, CT enterography, small-bowel endoscopy enteroscopy , capsule endoscopy which uses a small pill-like camera that is swallowed , technetium-labeled colloid or red blood cell RBC scan, and angiography should be considered.
Capsule endoscopy is of limited value in an actively bleeding patient. Hematemesis, hematochezia, or melena should be considered an emergency. Admission to an intensive care unit or other monitored setting, with consultation by both a gastroenterologist and a surgeon, is recommended for all patients with severe GI bleeding. General treatment is directed at maintenance of the airway and restoration of circulating volume.
Hemostasis and other treatment depend on the cause of the bleeding. A major cause of morbidity and mortality in patients with active upper GI bleeding is aspiration of blood with subsequent respiratory compromise. To prevent these problems, endotracheal intubation should be considered in patients who have inadequate gag reflexes or are obtunded or unconscious—particularly if they will be undergoing upper endoscopy.
Intravenous access should be obtained immediately. Short, large-bore eg, to gauge IV catheters in the antecubital veins are preferable to a central venous catheter unless a large 8. IV fluids are initiated immediately, as for any patient with hypovolemia or hemorrhagic shock see Intravenous Fluid Resuscitation Intravenous Fluid Resuscitation Almost all circulatory shock states require large-volume IV fluid replacement, as does severe intravascular volume depletion eg, due to diarrhea or heatstroke.
Intravascular volume deficiency Patients requiring further resuscitation should receive transfusion with packed RBCs. Transfusions continue until intravascular volume is restored and then are given as needed to replace ongoing blood loss.
Transfusions in older patients or those with coronary artery disease may be stopped when hematocrit is stable at 30 unless the patient is symptomatic. Younger patients or those with chronic bleeding are usually not transfused unless hematocrit is 23 or they have symptoms such as dyspnea or coronary ischemia.
Platelet count should be monitored closely; platelet transfusion may be required with severe bleeding. Patients who are taking antiplatelet drugs eg, clopidogrel , aspirin have platelet dysfunction, often resulting in increased bleeding. Platelet transfusion should be considered when patients taking these drugs have severe ongoing bleeding, although a residual circulating drug particularly clopidogrel may inactivate transfused platelets.
If patients are taking an antiplatelet drug or an anticoagulant for a recent cardiovascular indication, a cardiologist should be consulted, if possible, prior to stopping the drug, reversing the drug, or giving a platelet transfusion.
If a significant blood transfusion is required, fresh frozen plasma and platelets also should be transfused along with packed RBCs according to the institution's massive transfusion protocols. If the patient has a coagulopathy, correction with fresh frozen plasma or prothrombin complex concentrate should be considered. Octreotide a synthetic analog of somatostatin is used in patients with suspected variceal bleeding.
The remaining patients require some type of intervention. Specific therapy depends on the bleeding site. Early intervention to control bleeding is important to minimize mortality, particularly in elderly patients. For peptic ulcer Peptic Ulcer Disease A peptic ulcer is an erosion in a segment of the gastrointestinal mucosa, typically in the stomach gastric ulcer or the first few centimeters of the duodenum duodenal ulcer , that penetrates Nonbleeding vessels that are visible within an ulcer crater are also treated.
If endoscopy does not stop the bleeding, angiographic embolization of the bleeding vessel may be attempted, or surgery is required to oversew the bleeding site. Hemostatic powder may be used as a temporizing agent, especially for peptic ulcers or cancer.
If the patient has been treated medically for peptic ulcer disease but has recurrent bleeding, surgeons do acid-reduction surgery Surgery A peptic ulcer is an erosion in a segment of the gastrointestinal mucosa, typically in the stomach gastric ulcer or the first few centimeters of the duodenum duodenal ulcer , that penetrates Active variceal bleeding Treatment Varices are dilated veins in the distal esophagus or proximal stomach caused by elevated pressure in the portal venous system, typically from cirrhosis.
Severe, ongoing lower GI bleeding caused by diverticula Colonic Diverticulosis Colonic diverticulosis is the presence of one or more diverticula in the colon. Polyps can be removed by snare or cautery. If these methods are ineffective or unfeasible, angiography with embolization or vasopressin infusion may be successful. However, because collateral blood flow to the bowel is limited, angiographic techniques have a significant risk of bowel ischemia or infarction unless super-selective catheterization techniques are used.
Also, there is a risk of hypertension and coronary ischemia. Furthermore, angiography can be used to localize the source of bleeding more accurately. If the bleeding site cannot be localized, subtotal colectomy is recommended. However, assessment must be expeditious so that surgery is not unnecessarily delayed.
Acute or chronic bleeding of internal hemorrhoids stops spontaneously in most cases. Patients with refractory bleeding Treatment Hemorrhoids are dilated vessels of the hemorrhoidal plexus in the anal canal. Gastrointest Endosc 80 2 —, In the elderly, hemorrhoids Hemorrhoids Hemorrhoids are dilated vessels of the hemorrhoidal plexus in the anal canal.
Peptic ulcer Peptic Ulcer Disease A peptic ulcer is an erosion in a segment of the gastrointestinal mucosa, typically in the stomach gastric ulcer or the first few centimeters of the duodenum duodenal ulcer , that penetrates Hematochezia and melena usually have different causes, but their treatments are very similar. Your doctor will start by focusing on stopping the bleeding. Your doctor might use one or more of the following treatments, depending on the source of your bleeding:.
Hematochezia and melena both refer to having blood in your stool. While hematochezia causes bright red blood to appear in or around your stool, melena causes dark stools that often feel sticky. The difference in color is due to different bleeding sources.
The dark blood associated with melena comes from your upper GI tract, while the red blood of hematochezia comes from your lower GI tract. Blood in the stool has multiple causes, such as hemorrhoids and anal fissures.
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