🔅GI BLEEDING

– Gastrointestinal (GI) bleeding is a symptom of a disorder in the digestive tract. The blood often shows up in stool or vomit but isn't always obvious. Stool may look black or tarry. Bleeding can range from mild to severe and can be life-threatening. Imaging technology or an endoscopic investigation can usually locate the cause of the bleeding. Treatment depends on the where the bleeding is located and how severe it is. GI bleeding can happen either in the upper or lower gastrointestinal tract.

Causes of upper GI bleeding can include:

i) Peptic ulcer disease: This is a condition where ulcers or sores develop in the stomach or duodenum (the first part of the small intestine). The ulcers can bleed and cause melena. Peptic ulcers can be caused by infection with H. pylori bacteria, chronic use of aspirin or NSAIDs, or excessive acid production.

ii) Gastritis or esophagitis: These are inflammations of the stomach or esophagus, respectively, that can damage the lining of the GI tract and cause bleeding. Gastritis or esophagitis can be caused by GERD, alcohol, smoking, stress, or certain medications.

iii) Erosive gastropathy: This is a condition where the stomach lining is eroded by various factors, such as stress, shock, burns, or critical illness. The erosion can lead to bleeding and melena.

iv) Varices: These are swollen and fragile veins in the esophagus or stomach that can rupture and bleed. Varices are usually caused by portal hypertension, which is high blood pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can be caused by liver disease, such as cirrhosis.

v) Mallory-Weiss tear: This is a tear or laceration in the lower esophagus that can occur due to violent vomiting, coughing, or straining. The tear can bleed and cause melena.

vi) Tumors: These are abnormal growths of cells that can occur in the stomach, esophagus, or pancreas. Some tumors can be benign (non-cancerous), such as lipomas, while others can be malignant (cancerous), such as adenocarcinomas, squamous cell carcinomas, or carcinoid tumors. Tumors can bleed and cause melena.

vii) Viral hemorrhagic fevers: These are rare and serious infections caused by certain viruses, such as Ebola, that can affect multiple organs and cause bleeding throughout the body. Melena can be a sign of viral hemorrhagic fever.

Causes of lower GI bleeding can include:

i) Hemorrhoids: These are swollen veins in the lower rectum that can rupture and bleed, especially after straining during bowel movements. They are usually caused by obesity, pregnancy, or chronic constipation.

ii). Diverticulosis: These are small pouches that form in the wall of the colon and can bleed if they become inflamed or infected. They are more common in older people and those who consume a low-fiber diet.

iii) Inflammatory bowel disease (IBD): This is a group of conditions that cause chronic inflammation and ulcers in the GI tract, such as ulcerative colitis and Crohn's disease. They can affect any part of the GI tract, but ulcerative colitis mainly affects the colon and rectum, while Crohn's disease can affect any segment from the mouth to the anus.

iv) Colorectal cancer: This is a malignant tumor that grows in the colon or rectum and can bleed or obstruct the bowel. It is the third most common cancer and the second leading cause of cancer death worldwide. Risk factors include age, family history, smoking, alcohol, obesity, physical inactivity, and diet.

v) Angiodysplasia: These are abnormal blood vessels in the colon that can bleed spontaneously or due to low blood flow. They are more common in older people and those with chronic kidney disease, aortic stenosis, or von Willebrand disease.

vi) Anal fissure: This is a small tear or crack in the skin of the anus that can bleed and cause pain during bowel movements. It is usually caused by trauma, such as passing a hard stool, or by conditions that increase anal pressure, such as constipation, diarrhea, or childbirth.

vii) Polyps: These are benign growths that can develop in the colon or rectum and can bleed or become cancerous over time. They are more common in older people and those with a family history of polyps or colorectal cancer.

Other less common or rare causes of GI bleeding include:

i) Infectious colitis: This is an inflammation of the colon caused by bacteria, viruses, parasites, or fungi. Some examples are shigella, salmonella, E. coli, campylobacter, C. difficile, amebiasis, and giardiasis. Symptoms include diarrhea, fever, abdominal pain, and blood or mucus in the stool.

ii) Ischemic colitis: This is a reduced blood supply to the colon due to a blockage or narrowing of the arteries that supply the colon. It can cause abdominal pain, bloody diarrhea, and fever. Risk factors include age, atherosclerosis, diabetes, heart disease, and low blood pressure.

iii) Radiation colitis: This is a damage to the colon caused by radiation therapy for cancer. It can cause diarrhea, bleeding, pain, and ulcers in the colon. It can occur during or after the radiation treatment, and may be acute or chronic.

iv) Intussusception: This is a condition where a part of the intestine slides into another part, causing a blockage and reduced blood flow. It can cause abdominal pain, vomiting, bloody stool, and a palpable mass in the abdomen. It is more common in infants and children, but can also occur in adults due to tumors, polyps, or other abnormalities.

v) Meckel's diverticulum: This is a congenital abnormality where a small pouch remains from the fetal umbilical cord. It is usually located near the end of the small intestine and can contain gastric or pancreatic tissue that can bleed or ulcerate. It can cause painless rectal bleeding, especially in children.

vi) Dieulafoy's lesion: This is a rare condition where a large artery protrudes through a small defect in the mucosa of the GI tract and can bleed massively. It can occur anywhere in the GI tract, but most commonly in the stomach. It can cause hematemesis (vomiting blood), melena, or hematochezia.

– The diagnosis of GI bleeding depends on the history, physical examination, and laboratory tests of the patient. Some of the tests that can be used to determine the source and severity of the bleeding are:

• Fecal occult blood test (FOBT): This is a test that detects hidden blood in the stool. A positive FOBT indicates that there is bleeding somewhere in the GI tract, but it does not specify the location or cause.

• Endoscopy: This is a procedure that uses a flexible tube with a camera and light to examine the inside of the GI tract. Endoscopy can identify the site and cause of the bleeding, such as ulcers, polyps, or tumors. Endoscopy can also be used to treat some of the bleeding causes, such as by applying clips, bands, or injections to stop the bleeding.

• Colonoscopy: This is a type of endoscopy that examines the entire colon and rectum. It is the gold standard for diagnosing and treating lower GI bleeding.

• Sigmoidoscopy: This is a type of endoscopy that examines the lower part of the colon and rectum. It is less invasive than colonoscopy, but may miss some causes of bleeding in the upper part of the colon.

• Capsule endoscopy: This is a procedure that uses a small, pill-sized camera that is swallowed by the patient. The camera travels through the GI tract and takes pictures that are transmitted to a recorder. Capsule endoscopy can be useful for examining the small intestine, which is difficult to reach by conventional endoscopy.

• Angiography: This is a procedure that uses contrast dye and X-rays to visualize the blood vessels in the GI tract. Angiography can locate the bleeding vessel and also be used to deliver embolization, which is a technique that blocks the bleeding vessel with a coil or a plug.

• Blood tests: These are tests that measure the levels of hemoglobin, hematocrit, platelets, and coagulation factors in the blood. Blood tests can indicate the extent of blood loss and the risk of bleeding complications.

– The treatment of GI bleeding depends on the cause and severity of the bleeding. Some of the treatment options include:

• Medications: These are drugs that can reduce inflammation, infection, acid production, or bleeding in the GI tract. Some examples are antibiotics, anti-inflammatory drugs, proton pump inhibitors, H2 blockers, antacids, sucralfate, or octreotide.

• Fluids and blood transfusions: These are interventions that can restore the fluid and blood volume that is lost due to bleeding. Fluids and blood transfusions can prevent dehydration, shock, and anemia.

• Surgery: This is an option that can be used to remove or repair the source of bleeding, such as ulcers, tumors, polyps, or perforations. Surgery can also be used to create a bypass or shunt to reduce portal hypertension and prevent variceal bleeding.

Prognosis of GI Bleeding

– The prognosis of GI bleeding depends on several factors, such as the cause, location, severity, and treatment of the bleeding, as well as the patient's age, comorbidities, and response to therapy.

In general, upper GI bleeding has a higher mortality rate than lower GI bleeding, ranging from 5% to 15%. Lower GI bleeding has a mortality rate of less than 5%, but it can be higher in elderly patients or those with significant blood loss or shock.

Some of the factors that are associated with a poor prognosis of GI bleeding are:

• Advanced age.

• Comorbid conditions, such as: cardiovascular disease, renal failure, liver cirrhosis, or malignancy.

• Shock or hypotension.

• Severe or persistent bleeding.

• Need for transfusion or surgery.

• Rebleeding or recurrent bleeding.

• Delayed diagnosis or treatment.

• High-risk endoscopic findings, such as: active bleeding, visible vessel, or adherent clot.

• High-risk clinical scores, such as Rockall or Blatchford scores.

– The prognosis of GI bleeding can be improved by early and accurate diagnosis, appropriate and timely treatment, and prevention of complications and recurrence. Some of the measures that can improve the prognosis of GI bleeding are:

• Seeking medical help as soon as possible if you have symptoms of GI bleeding, such as vomiting blood, black or tarry stools, rectal bleeding, or signs of shock.

• Following your doctor's instructions for treatment and follow-up, such as taking medications, undergoing endoscopy or surgery, or having regular screenings for colorectal cancer.

• Making lifestyle changes to prevent or reduce the risk of GI bleeding, such as avoiding alcohol, smoking, spicy foods, or NSAIDs, managing stress, and following a balanced diet.

• GI bleeding is a serious condition that can have various causes and complications. The prognosis of GI bleeding depends on several factors and can vary from mild to severe. GI bleeding can be diagnosed and treated by various tests and procedures. GI bleeding can be prevented or reduced by taking medications, making lifestyle changes, and seeking medical help when needed.

Reducing Risks of GI Bleeding if you have Liver Cirrhosis

– If you have liver cirrhosis, you are at a higher risk of developing gastrointestinal (GI) bleeding due to portal hypertension, which is high blood pressure in the veins that lead to your liver. Portal hypertension can cause varices, which are swollen and fragile veins in the esophagus or stomach that can rupture and bleed. Portal hypertension can also cause portal hypertensive gastropathy, which is an inflammation of the stomach lining due to changes in blood pressure. Both conditions can cause upper GI bleeding, which can be life-threatening.

To reduce your risk of GI bleeding if you have liver cirrhosis, you should follow these steps:

• Avoid alcohol:- Alcohol can worsen the damage to your liver and increase the pressure in your portal vein. Alcohol can also irritate or damage the lining of your GI tract and interfere with blood clotting. Excessive alcohol consumption can also cause liver disease, which can lead to portal hypertension and variceal bleeding. If you drink alcohol, do so in moderation, which means no more than one drink per day for women and two drinks per day for men.

• Quit smoking:- Smoking can worsen the symptoms and healing of peptic ulcers, and increase the risk of gastric cancer. Smoking can also impair blood circulation and oxygen delivery to the GI tract, which can contribute to ischemic colitis. Quitting smoking can improve your overall health and reduce your risk of many diseases.

• Manage your stress:- Stress can affect your digestive system and cause or aggravate conditions such as gastritis, esophagitis, or inflammatory bowel disease. Stress can also trigger the release of hormones that increase acid production and inflammation in the stomach. To cope with stress, you can try relaxation techniques, such as deep breathing, meditation, yoga, or tai chi. You can also seek professional help or join a support group if you have trouble managing your stress.

• Follow a balanced diet: Eating a healthy and varied diet can help prevent or treat some of the causes of GI bleeding, such as anemia, diverticulosis, or colorectal cancer. A balanced diet should include plenty of fruits, vegetables, whole grains, lean proteins, and low-fat dairy products. You should also limit your intake of fatty, spicy, or acidic foods, which can irritate your GI tract. You should also drink enough fluids to stay hydrated and prevent constipation, which can cause hemorrhoids or anal fissures.

• Seek medical help when needed:- If you have any symptoms of GI bleeding, such as vomiting blood, black or tarry stools, rectal bleeding, or signs of shock, you should seek immediate medical care. If you have a history of GI bleeding or a condition that increases your risk, such as peptic ulcer, inflammatory bowel disease, or liver disease, you should follow your doctor's instructions for treatment and follow-up. You should also get regular screenings for colorectal cancer, especially if you are over 50 years old or have a family history of the disease.

These are some of the ways you can reduce your risk of GI bleeding if you have liver cirrhosis. However, you should always consult your doctor before making any changes to your medication, diet, or lifestyle, as they may have specific recommendations for your condition.