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Gastrointestinal Bleeding

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Muhammad Waleed Haider, M.D.[2]

Synonyms and Keywords: Blood loss from GI tract; bloody stool; blood in feces; PR bleeding; gastrointestinal hemorrhage; gastrointestinal hemorrhage; GI bleeding; bright red blood per rectum; BRBPR.


Gastrointestinal (GI) bleeding is defined as bleeding from any part of GI tract starting from mouth to anus. It can also be called as gastrointestinal hemorrhage. Based on the origin of bleeding it can be classified into upper gastrointestinal bleeding and lower gastrointestinal bleeding. Upper gastrointestinal bleeding (UGIB) is defined as bleeding from the gastrointestinal tract that originates proximal to the ligament of Treitz. Lower gastrointestinal bleeding is defined as blood loss originating distal to the ligament of Treitz. The most common causes of UGIB are peptic ulcer disease and esophageal varices while diverticulosis is the most commonly responsible for lower gastrointestinal bleeding. Clinical presentation includes overt bleeding from the gastrointestinal tract, rapid or slow, either manifested by hematemesis of fresh (blood-streaked to frankly bloody), old ('coffee ground') vomitus, melena and or as frank blood per rectum.

Common risk factors in the development of GI bleeding include advancing age, previous history of gastrointestinal bleeding, chronic constipation, hematologic disorders, anticoagulants medications, NSAIDs. It is essential to distinguish between lower gastrointestinal bleeding and brisk upper gastrointestinal bleeding as they can present with similar symptoms. Patients with severe bleeding or hemodynamic disturbance require hospitalization and urgent investigation. Treatment depends on the cause and the severity of the bleeding.

Types of bleeding

Bleeding from the gastrointestinal tract can be of the following types:

  • Hematemesis: Vomiting fresh red blood.
  • Coffee ground emesis: Vomiting of altered black blood.
  • Melena: Passage of black tarry stools.
  • Hematochezia: Passage of red blood per rectum (usually due to bleeding from the lower gastrointestinal tract but occasionally can be due to massive upper gastrointestinal bleeding).
  • Rebleeding: Defined as fresh hematochezia and/or melena associated with the development of shock (pulse greater than 100 beats/min, systolic pressure less than 100 mm Hg), a fall in CVP greater than 5 mm Hg, or a reduction in hemoglobin concentration greater than 20 g/l over 24 hours. Rebleeding should always be confirmed by endoscopy.


Gastrointestinal Bleeding Lethal Causes Common causes Less Common causes
Upper gastrointestinal bleeding
  • Anthrax
  • Ebola virus
  • Duodenal ulcer
  • Esophagitis
  • Esophageal varices
  • Gastric tumors
  • Gastric ulcer
  • Gastritis
  • Mallory-Weiss Syndrome
  • Peptic ulcer
  • Gastric cancer
  • Esophageal Tumors
  • Esophagitis
  • Gastric erosions/gastropathy
  • Dieulafoy lesions
  • Gastric antral vascular ectasia
Lower gastrointestinal bleeding
  • Diverticulosis
  • Vascular ectasias
  • Ischemic colitis
  • Colorectal malignancy
  • Hemorrhoids
  • Anal fissures
  • Crohn's disease
  • Ulcerative colitis
  • Infectious colitis
  • Colonic polyps
  • Radiation proctitis
  • Rectal varices
  • Stercoral ulceration
  • Meckel diverticulum
  • Intussusception
  • Henoch-Scholein Purpura (HSP)


The following flow chart elobarates the classification of gastrointestinal bleeding:

Gastointestinal bleeding
Upper GI bleedingLower GI bleeding
Based on blood lossBased on severity of blood loss