GIT BLEEDING

GIT bleeding may be broadly divided into three categories:

a. Hematemesis, i.e. blood-mixed vomitus containing either fresh blood suggestive of oropharyngeal, esophageal or gastric bleeding, or altered blood due to acid hematin formation in gastric bleeding.

b. Melena, i.e. dark tarry stools containing altered blood suggestive of upper GIT bleeds after a few hours, due to downward passage of blood.

c. Hematochezia, i.e. passage of fresh blood in stools, suggestive of colorectal or anal bleed.

Etiology: GIT bleeding indicates either a local pathology or a systemic bleeding diathesis (Table 14.7). Esophageal varices or drug-induced gastritis are predominant causes of hematemesis and melena, while hematochezia usually indicates local pathology, e.g. anal fissures.

Diagnostic evaluation of GIT bleeding depends on the clinical presentation—hematemesis, melena or hematochezia. Other important etiological clues include:

• Detailed history, specially regarding-age of onset, coexisting abdominal pain, diarrhea, constipation or painful defecation, recent drug ingestion or worm infestation and past history of similar attacks.

• Physical examination specially for signs of nasal/ dental bleed, portal hypertension, abdominal

TABLE 14.7: Causes of GIT bleeding

A. Swallowed blood: Maternal*, epistaxis, caries

B. Upper GIT bleed: (Hematemesis/ Melena)

- Esophageal : Varices, esophagitis, foreign body

- Gastric : Acute gastritis, stress/peptic ulcer

Mallory-Weiss syndrome

C. Lower GIT bleed (Hematochezia)

- Intestinal : Dysentery, IBD, NEC*, intussusception

Meckel's diverticulum#, milk allergy#, Hookworm infestation^#

- Anorectal : Fissures, hemorrhoids, polyps, trauma

D. Systemic : HDN*, septicemia, DIC, ITP, HSP.

IBD: Inflammatory bowel diseases, HSP: Henoch-Schonlein purpura HDN: Hemorrhagic disease of newborn, ITP: Idiopathic thrombo­cytopenic purpura

*common causes in newborns, #occult bleeding.

tenderness, anal fissure as well as sepsis or bleeding diathesis, e.g. purpura. In cases of massive bleeds, it is important to assess the severity of anemia (pallor) and circulatory insufficiency (hypotension/shock).

• Relevant investigations depending on probable site of bleed and include:

- Endoscopy, i.e. esophagoscopy (for hematemesis) and proctoscopy/colonoscopy (for hematochezia) in severe or persistent unexplained bleeding.

- Stool exam for occult blood and ova/cysts.

- Plain/contrast radioimaging studies, specially to identify small intestinal causes - a region not easily accessible through endoscopes.

- Screening for bleeding disorders, e.g. BT/CT, platelet count, coagulation profile, etc.

- Sepsis screening, including blood cultures in suspected septic cases.

Differential diagnosis of common causes of GIT bleeding are as follows:

• Swallowed blood is usually miniscule in amount, with prior history of epistaxis or gingival bleeding.

• Esophageal bleeding usually presents with sudden, large vomiting of fresh blood without gastric contents. Esophageal varices due to portal hypertension are the commonest cause of recurrent hematemesis. Retrosternal burning pain may be present in early cases.

Gastric bleeding is common after ingestion of drugs, e.g. chloroquine or NSAIDs, and contains undigested food. Mallory-Weiss syndrome denotes hematemesis due to longitudinal mucosal tear at gastroesophageal junction or gastric cardia, following forceful vomiting/ retching, irrespective of cause.

Meckel's diverticulum is the commonest cause of recurrent painless hematochezia/melena, though abdominal pain may be present.

TABLE 14.8: Causes of abdominal distension

TABLE 14.9: Causes of abdominal mass/lump

• Physiological: Obesity, constipation

• Hypotonia: PEM, rickets, hypothyroidism

• Fluid: Ascites, peritonitis

• Gaseous distension:

- Aerophagia (swallowed air)

- Malabsorption: Lactose intolerance, gastroenteritis

- Stasis, e.g. intestinal obstruction, paralytic ileus

• Intra-abdominal solids:

- Intestinal, e.g. fecoliths, Hirschsprung disease

- Hepatosplenomegaly

- Tumors

• Hookworm infestation is the commonest cause of occult bleeding in Indian children, while cow-milk allergy is common in infants.

• Intestinal polyps lead to painless bleeding which is rarely severe. Peutz-Jeghers syndrome is an autosomal disorder, characterized by intestinal polyposis and perioral pigmentation.

• Anal fissures are the commonest cause of painful hematochezia, associated with constipation.

14.4.6