Aging Begins at 30

Bleeding from the Gut

If you vomit blood or pass blood from the rectum it scares you; and so it should because it can be life threatening. There are 300,000 U.S. hospital admissions yearly for this expensive problem. Gastrointestinal (GI) blood loss occurs five times more often in people over 65 than in younger people. Overall, 10% die of the blood loss.

Vomiting blood is called hematemesis, passing it hematochezia (from chezen to go to stool). Black, sticky, tarry stools indicate blood changed in color by stomach juice and is called melena.

The greatest risk is for elderly male smokers with a peptic ulcer who are taking steroids or NSAIDS (nonsteroidal anti inflammatory drugs such as aspirin, ibuprofen or naprosyn). Another large group is elderly women taking NSAIDS for ill-defined back pain. NSAID users have four times the risk of bleeding. Half the NSAIDs are used in the over sixty population.

We used to think that G.I. ulcers were caused by the erosive effect of acid peptic juice in the mucosa. We know now that in peptic ulcer disease Helicobacter pylori infection is more important. NSAIDs deplete the prostaglandins which support the gut lining cells. H. pylori makes the lining susceptible to acid damage.

GI bleeders will feel faint, have weakness, may have shortness of breath, will sweat, and can have confusion or seizures.

Loss of blood volume is initially counteracted by intravenous saline and later by typed and cross-matched blood transfusion. The history and physical will accurately indicate the site of bleeding in 50%, otherwise looking inside with special scopes (gastroscope or colonoscope). In the upper GI tract, about 25% are caused by duodenal ulcers, another 25% from gastric erosions, 20% from gastric ulcers, and 10% from varicose veins at the esophagus and stomach join. These are caused by blockage of liver veins in liver disease, usually from alcohol. In the lower tract, the most common causes include multiple outpouchings of the colon lining with overstretched vessels (divuerticulosis). It is arterial bleeding and can be severe. Vascular ectasia (spider like ballooning of colon lining veins) is venous bleeding and often less massive. Cancer of the colon usually causes a slow non-visible loss of blood, but the loss can be massive.

Heart attacks (old or new), strokes, cancer, diabetes, and general frailty will worsen the outlook for survival. Age (the older the worse), gender (men more), medicine (NSAIDs) all play a role independent of the GI disease. A bad outlook is predicted if the hemoglobin falls below 10 (normal 14), the blood pressure below 80 (normal 120), or six or more pints of blood are needed.

Diagnosis is helped by angiography - x-ray visualization of blood vessels - which will reveal a source of bleeding in 80%, if the bleeding is still active.

Bleeding can be stopped under direct vision by electro or heat coagulation through an endoscope. Artificial plugs (emboli) can be used to block bleeding vessels. Intravenous vasopressin (blood vessel contracting hormone) is effective about half the time. Bleeding can recur in a few days in 25%. Surgery is needed in about 10%. Correct treatment depends on a carefully made, accurate diagnosis.

Section Top | Title Page

See related Patient Topics Digestive System, Gastrointestinal Bleeding or Symptoms and Manifestations.

See related Provider Topics Digestive System, Gastrointestinal Bleeding or Symptoms and Manifestations.

All contents copyright © 1992-2004 the Author(s) and The University of Iowa. All rights reserved.

http://www.vh.org/adult/patient/internalmedicine/aba30/1994/gibleed.html