Gastrointestinal Bleeding: A Cause for Concern

By Dr. Anis Ansari

Gastrointestinal bleeding (GIB) can be a matter of great anguish to patients. When they are informed of the bleeding, extent of the problem may not be known. It could be just simple peptic ulcer or colon cancer. Only a complete work up can reveal the extent of problem.  It is estimated that more than 100,000 Americans are hospitalized with a GIB and between 15,000 to 20,000 die each year from an ulcer or GI bleed related to NSAID (Ibuprofen, Aleve or Motrin) use. There are 14 million arthritis patients who use NSAID’s regularly and up to 60% may experience GI side effects. It can be from slow or undetectable to massive and life threatening.

GIB are divided between upper and lower. An upper GI bleed refers to bleeding from pharynx to end of the stomach. It can present as vomiting of blood or coffee-ground material, stomach pain, or black stools. Peptic Ulcers are most common cause of upper GIB accounting for almost 50 percent of cases mostly caused by over the counter arthritis medication. Other causes include erosion of esophagus, duodenal ulcer, or variceal bleeding secondary to liver cirrhosis or Mallory-Weiss tear (tear in the lining of esophagus) due to cough or retching. The incidence of ulcers caused by H. Pylori bacteria is decreasing.

GI B are becoming more common due to newer anti-coagulation medications that are used to treat chronic non-valvular atrial fibrillation or pulmonary embolism, or just deep venous thrombosis e.g. Dabigatran (Pradaxa) or rivaroxaban (Xarelto), and warfarin (Coumadin).  Risk of bleeding with Pradaxa is increased by greater than 30% than with Coumadin. Short term medication used in the hospital for DVT prophylaxis like Lovenox or Heparin can also do that. Upper GIB is much more common than the lower GIB. Incidence of upper GI bleeding is 50 to 150 per 100,000 adults per year while lower GI bleeding is 20 to 30 per 100,000.

Lower GI bleeding refers to bleeding from the colon or the rectum. The most common cause of bleeding is diverticulosis followed by hemorrhoids, vascular ectasia, ulcer, colonic polyps or cancer. In renal failure patients, vascular ectasia is the most common cause of upper or lower GIB. Symptoms of lower GI bleeding can include fresh blood in the stool, pain on defecation, and abdominal pain.  Patient will usually feel weak, tired, and pale. With rapid bleed they can have rapid heart rate, and low blood pressure. A blood test like hemoglobin can show the rate of decline specifically by comparing to previous one. CT angiography or bleeding scan can be used to determine the exact location of the bleeding.

Treatment depends on the diagnosis, location and severity of GI bleed.  Most of minor bleeding stops on its own.  Upper GI bleeding usually requires upper endoscopy, use of Proton Pump Inhibitors, cauterization or injection of epinephrine during the procedure to stop the bleeding or surgery in case of severe bleeding. Capsule enteroscopy is used to diagnose any mass lesion in small intestine. Most common lesion in the small intestine is vascular ectasia and tumor. Colonoscopy is the most useful in diagnosing of lower GI B. The bleeding site can be cauterized and medication can be injected to stop the bleeding.  In case of mass or suspicious lesion, a biopsy can be performed at the same time. Serious bleeding requires prompt blood transfusion, urgent colonoscopy and admission to ICU.
One third of the patient with bleeding ulcer will rebleed within 1-2 years. Death is usually attributed to major illnesses like cancer or cirrhosis.  Mortality rates in patients admitted with a GI bleed is about 7%.  Despite treatment, re-bleeding occurs in about 7-16% of those with upper GI bleeding.

Evaluation of positive occult blood test generally begins with colonoscopy, particularly in patient more than 40 years of age. If evaluation of colon is negative, then many perform upper endoscopy only if Iron deficiency anemia or upper GI symptoms are present. If both scopes are unrevealing then video capsule enteroscopy may be considered inpatient with Iron deficiency anemia.

Prevention depends on 3 main factors in ulcer pathogenesis, H.Pylori, NSAID and acid. Eradication of H. Pylori in patients with bleeding ulcers decreases rate of rebreeding to less than 5 percent. Changes of NSAID to COX-2 Inhibitor (Celebrex) or chronic use of Proton pump inhibitor in highest risk patient will be another strategy.

Conclusion:  GI bleeding is a serious condition that needs to be handled in a timely fashion.  GI bleeding has become more common due to common use of aspirin, arthritis medication and blood thinners.  More education and close coordination with their physician is required to handle this problem efficiently.

Anis Ansari, MD
Chairman, Department of Medicine
Mercy Medical Center
Clinton, Iowa

15-8