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Gastrointestinal Bleeding: An Evidence-Based ED Approach To Risk Stratification

March 2004

Abstract

Problems associated with GI bleeding are challenging for patients and physicians. Seemingly deadly bright red blood from the anus can arise from simple, benign hemorrhoids. Robust patients with brown stools that test positive for occult blood, on the other hand, may harbor a deadly malignancy or a rapidly fatal aortoenteric fistula.

Blood in the GI tract may not present in a way that is readily apparent to patients. When digested blood is expelled as coffee-ground vomitus or as black diarrhea, patients may not even recognize this as bleeding. On the other hand, there are times when there appears to be GI bleeding when there is not. Both unsuspecting physicians and patients may be misled by foods or medications that alter the appearance of stools in such a way as to simulate GI bleeding when, in fact, there is none. These challenges are perhaps greatest for chronic alcoholics, who are frequently stricken by GI bleeding and have both social problems and physiologic abnormalities that increase the risk of serious complications.

Bleeding in the GI tract is, to some extent, mysterious. The actual location of the bleeding is seldom immediately apparent based solely on the history and physical examination. Even after endoscopic evaluation, this may remain elusive. In addition to the location being unclear, the cause of the bleeding can also be difficult to determine. The etiologies are myriad and include infections, malignancies, vascular disorders, medication effects, and coagulopathies. The treatments available are similarly diverse, include ing antibiotics, surgical excision, endoscopically guided procedures, and medications.

Given all of these initial difficulties, the prognosis is sometimes just a guess. Bleeding that initially seems inconsequential may rapidly become deadly. Bleeding that is initially very frightening to all involved may spontaneously resolve without consequence. Fortunately, evidence-based risk stratification can help the emergency physician move past these uncertainties and offer the patient the best information possible.

This article sheds light on some of the more mysterious aspects of GI bleeding. A practical, evidence-based approach emphasizing a strategic plan for addressing the needs of patients with suspected GI bleeding who present to the ED is provided.

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