Whether a case of gastrointestinal (GI) bleeding is serious or not, it always warrants investigation, says Dr. Sanjeewa Aryasingha, Consultant Gastroenterologist and Hepatologist. Originating somewhere along the gastrointestinal tract, the blood escapes the body either through the rectum or the mouth, staining vomit red or producing blood stained or black tarry stools.
People who notice such symptoms would be well advised to seek a doctor’s opinion as soon as possible, emphasises Dr. Aryasingha, explaining that the causes cover the spectrum from ulcers to haemorrhoids and gastric cancer - some easily treatable, others requiring immediate intervention.
The oesophagus, stomach, small intestine, colon, rectum, and anus are all a part of the digestive or gastrointestinal (GI) tract. A process of elimination is required to identify which of these areas bleeding might have originated in – it could be anything from an anal fissure to an inflammation of the oesophagus (esophagitis). While patients may be aware of some of these conditions, thanks to either pain or other symptoms, occasionally bleeding goes unnoticed. This type is known as occult or hidden bleeding but Dr. Aryasingha says it can be detected with a simple stool test or endoscopy.
In many such cases, Dr. Aryasingha’s patients are directed to him by general physicians. Patients may have complained of ambiguous symptoms such as tiredness, weakness and palpitations, while a blood test would have revealed low Haemoglobin levels. (Hemoglobin (Hb) is the protein that occurs in red blood cells that allows them to carry oxygen.)
A number of conditions are connected with low Hb counts and doctors will have to sift through all the symptoms in order to diagnose the problem.
That heavy bleeding from the GI tract can be life threatening won’t come as a surprise. However, even very small amounts of bleeding, stretched over a long period of time can have an effect. Broadly, GI bleeding can be categorized based on which part of the tract it occurs in, says Dr. Aryasingha – either Upper GI bleeding UGIB or Lower GI bleeding LGIB.
Upper GI bleeding:
This kind of bleeding originates in the upper part of the GI tract: the oesophagus, stomach, or duodenum (first part of the small intestine). UGIB has been connected to conditions like peptic ulcers, gastritis, oesophageal varices, Mallory-Weiss tears, and gastric cancers, says Dr. Aryasingha, explaining that traces of blood may be seen if the patient vomits. Peptic ulcers, the commonest cause of GI bleeding, form around tissue which has been eaten into by gastric juices and stomach acid and can occur in the stomach itself or in duodenum (upper part of the small intestine). However, a certain type of bacteria, known as Helicobacter pylori, promotes the formation of ulcers, says Dr. Aryasingha, revealing that sometimes patients need to be tested for it. Such an infection may lead to chronic gastritis and even gastric cancer.
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Gastritis is a general inflammation of the stomach lining and can sometimes cause bleeding. It can be triggered by the use of NSAIDs (nonsteroidal anti-inflammatory drugs), steroids and alcohol. Smoking typically aggravates the condition. Another cause of internal bleeding is oesophageal varices. These swellings of the veins of the oesophagus or stomach are usually related to liver diseases such as cirrhosis. Some cases are extremely severe – varices can bleed massive, catastrophic amounts with little or no warning.
Even in the short term, a night of binging on alcohol has been known to leave patients with tears in their oesophageal lining known as Mallory-Weiss tears. These are often the result of activities such as vomiting or retching but have also appeared in people who have attempted heavy lifting or women who have undergone childbirth.
One of the earliest warning signs of stomach cancers is blood in the vomit or stool, explains Dr. Aryasingha. If there is a lot of fresh blood it is an indication of higher amounts of bleeding, whereas a slower rate of internal bleeding could result in the patient throwing up clumps of blood that look a little like coffee grounds, he adds.
Lower GI bleeding
When bleeding originates in the lower part of the GI tract it is known as Lower GI Bleeding or LGIB. This includes parts of the small intestine, the large intestine, rectum, and anus, explains Dr. Aryasingha. Diverticular disease, colon cancers, inflammatory bowel diseases like ulcerative colitis and Crohn’s Disease, haemorrhoids and anal fissures have all been known to cause bleeding. Of all these, haemorrhoids remains one of the most common causes of lower GI bleeding. They are common in people who have constipation or strain during a bowel movement. Diverticuli form in the wall of the large intestine, usually in a portion of the bowel wall that has been weakened.
As in the case with stomach cancers, blood, this time in the stool, is one of the early signs of colon or rectal cancers. Angiodysplasia is another cause of GI bleeding which is due to malformations of blood vessels in the wall of the GI tract, says Dr. Aryasingha. Angiodysplasia is common in the large intestine. Many patients with Angiodysplasia are to found among the elderly, with another at risk group being people with chronic kidney failure. Along with diverticulosis, this is one of the most common causes of lower GI bleeding.
Rectal bleeding and bloody stools are one of the known symptoms of inflammatory bowel disease, - ulcerative colitis and Crohn’s disease, though the symptoms depend on what part of the gastrointestinal tract is affected.
Haemorrhoids and fissures are among the more painful causes of lower GI bleeding. Here swollen veins in and around the anus bleed during bowel movements. Patients are advised to make dietary changes and avoid straining, says Dr. Aryasingha. Bleeding from haemorrhoids is usually light, intermittent and bright red as is the case with anal fissures which are tears in the anal wall. If blood is coming from the rectum or the lower colon, it is likely to be bright red, while darker blood is an indication that the bleeding is happening higher up. Bleeding in the oesophagus, stomach, or duodenum, usually results in stools that are black and tarry.
Diagnosing and
treating GI bleeding
Doctors will employ different treatments based on exactly what is causing the bleeding, says Dr. Aryasingha, explaining that these are as different as the diseases themselves. Diagnosing the patient correctly can be a challenge. Blood and stool tests can reveal the existence of a problem. The latter in particular can provide hints to the seriousness and duration of the problem. However, identifying the source of the bleeding often requires them to go looking inside the body.
To do so, a doctor might opt for an endoscopy says Dr. Aryasingha. This common procedure involves inserting a long, flexible instrument into the mouth or rectum with a small camera that allows the doctor to examine the patient from the inside thoroughly. Sometimes, the endoscope can be used to treat the problem as well.
Endoscopic therapies include band ligation of varices and injecting chemicals directly into the site of the bleeding with a needle attached to the endoscope. A doctor can also cauterize, or treat with heat, a bleeding site or place a clip on a bleeding blood vessel. However, sometimes surgery is required to manage severe or recurrent bleeding.
In recent years, Dr. Aryasingha has seen ‘capsule endoscopy’ become increasingly popular. The device used in Sri Lanka allows doctors to examine the small intestine, which is approximately 25 feet in length. The capsule captures images as it goes down the digestive tract and transmits pictures, he says. Once its work is done, it is passed out naturally. Capsules are also now available to examine the upper GI tract and the large intestine. Though the process is more expensive than the older tests, many patients who were squeamish about having the endoscope inserted prefer this, less painful, option.
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