Gastrointestinal bleeding

Disease Description (Causes and Symptoms)

• Definition: Gastrointestinal hemorrhage refers to bleeding that occurs when blood vessels are exposed due to mucosal damage in the esophagus, stomach, or duodenum (upper gastrointestinal tract), or the small or large intestine (lower gastrointestinal tract).
• Main causes
  • Upper: Peptic ulcers (approximately 50%), esophageal or gastric varices, stress ulcers, erosive gastritis, Mallory–Weiss tears (after vomiting), gastric cancer, etc.
  • Lower: Colonic diverticula, angiodysplasia, inflammatory bowel disease (ulcerative colitis, Crohn’s disease), infectious lesions such as tuberculosis and typhoid, colorectal cancer and polyps, hemorrhoids
  • Medications and mechanisms: NSAIDs, anticoagulants and antiplatelet agents, varices caused by severe cirrhosis, etc.
• Pathophysiology: Mucosal damage exposes blood vessels, resulting in rapid or persistent bleeding. Depending on the amount and rate of bleeding, systemic symptoms such as hypovolemic shock, tachycardia, and anemia may occur.
• Main symptoms
  • Hematemesis, melena (upper gastrointestinal bleeding), bright-red hematochezia (mainly lower gastrointestinal bleeding or massive upper gastrointestinal bleeding), fainting and dizziness, tachycardia, hypotension, and pallor, dyspnea (caused by anemia, shock, or aspiration)
  • In general, when the amount of blood loss is large (e.g., 1,000 mL or more), clear symptoms such as hematemesis, bloody stool, tachycardia, and hypotension occur

Treatment Methods

• Initial emergency care (priorities)
  • Prioritize ABC (airway, breathing, circulation). Airway suction and protection may be necessary (in cases of hematemesis).
  • Establish intravenous access (2 or more large-bore IV lines), administer fluids (crystalloids and, if necessary, blood transfusion), and monitor vital signs
  • Tests: CBC, blood typing and crossmatching, coagulation tests (PT/INR, aPTT), blood chemistry tests
• Medication treatment
  • If upper gastrointestinal bleeding is suspected, suppress gastric acid with an IV proton pump inhibitor (PPI) (to help stabilize the bleeding lesion)
  • If esophageal variceal bleeding is suspected, administer a vasoconstrictor (octreotide or terlipressin) and prophylactic antibiotics (recommended for patients with cirrhosis)
  • For patients taking anticoagulants or antiplatelet agents, consider discontinuation and reversal (vitamin K, PCC, platelet transfusion, etc., if necessary)
• Endoscopic treatment (simultaneous diagnosis and treatment)
  • Perform as early as possible (within 24 hours when stable, or emergency endoscopy when unstable)
  • Hemostatic methods: local epinephrine injection, thermal hemostasis (cauterization), hemostatic clips (hemoclips), and band ligation for varices (endoscopic ligation)
• Interventional radiology and surgery
  • If bleeding cannot be controlled endoscopically or the patient is at high risk for surgery, perform embolization through angiography
  • Surgical treatment is necessary in cases of persistent or severe recurrent bleeding (lesion removal and surgical hemostasis)
• Treatment and prevention of underlying diseases
  • Peptic ulcers: Test for Helicobacter pylori and provide eradication therapy; adjust maintenance PPI therapy if necessary
  • Varices: Treat cirrhosis and prevent variceal recurrence (endoscopic ligation, medication therapy, and management of the portal venous system)
• Lifestyle management and precautions
  • Depending on the cause of bleeding, NSAIDs, alcohol, and anticoagulants may need to be adjusted
  • Because there is a risk of recurrent bleeding after an episode, regular follow-up and management of risk factors are necessary
• Prognosis
  • Varies depending on the cause, amount of bleeding, and timeliness of treatment. Appropriate emergency and endoscopic treatment can control the bleeding in most cases, but the risks of recurrent bleeding and death remain

Checklist Before an Outpatient Visit (Including Preparation Items and Sample Questions)

• Items to prepare (before visiting the hospital)
  • List of medications currently being taken (including prescription drugs, over-the-counter medications, and herbal medicines), especially anticoagulants (warfarin, DOACs), antiplatelet agents (aspirin, clopidogrel), and NSAIDs
  • Copies or records of recent test results (blood tests, previous endoscopy findings, liver function tests, etc.)
  • Symptom record: time symptoms began, amount and color of hematemesis or bloody stool (e.g., bright red vs. black), accompanying symptoms (dizziness, fainting, etc.), and whether vomiting occurred recently
  • Medical history: gastric ulcer, liver disease, long-term anticoagulant use, previous bleeding, etc.
• Information to tell medical staff first during the outpatient visit
  • Whether severe dizziness, fainting, tachycardia, or hypotension has occurred recently
  • Whether there is currently severe vital-sign instability (in this case, visiting the emergency room is recommended)
• Sample questions (simple questions the patient can ask the doctor directly)
  • "Do I need to go to the emergency room for these symptoms?" / "When will I undergo endoscopy?"
  • "How should I adjust the medication I am taking (e.g., warfarin)?"

Examples of General Questions to Ask the Doctor

• What is the most likely cause of this bleeding?
• Given my current condition, do I need emergency endoscopy (or surgery)? When should it be performed?
• What are the criteria for requiring a blood transfusion (such as the hemoglobin level)?
• When should I stop and restart the anticoagulant or antiplatelet medication I am taking? Are reversal (reconstitution) measures necessary?
• What long-term management (medication and lifestyle) can reduce the risk of recurrent bleeding?
• Is testing for Helicobacter pylori and eradication therapy necessary, and what is the procedure?

Examples of Disease-Specific Questions

• When peptic ulcer is suspected: "Do I need to be tested for Helicobacter pylori and receive eradication therapy if positive? Do I need to take a PPI long term?"
• When there is a history of cirrhosis or esophageal varices: "Do I need endoscopic ligation or medication (beta-blocker) treatment to prevent variceal bleeding? If bleeding recurs, which treatment takes priority?"

Caution: If bleeding is suspected or vital signs (severe dizziness, fainting, tachycardia, hypotension, etc.) are unstable, go to the emergency room immediately.