CHRONIC PEPTIC ULCER. Since the advent of H2- receptor antagonists, omeprazole and the role of H. pylori in aetiology, every effort should be made to avoid surgery. If necessary to control haemorrhage the bleeding vessel is ligated, but no other surgical procedure is undertaken. Eradication of H. pylori is mandatory following a bleed.
GASTRIC CARCINOMA. Most patients do not have large bleeds with this condition but surgery may be performed for the lesion per se.
MALLORy-WEISS TEAR. This is a linear mucosal tear occurring at the oesophagogastric junction and produced by a sudden increase in intra-abdominal pressure. It often occurs after a bout of coughing or retching and is classically seen after an alcohol binge. There may, however, be no antecedent history of retching. The haemorrhage may be large but most patients stop spontaneously. Rarely, surgery with over-sewing of the tear will be required.
The mortality of gastrointestinal haemorrhage has not changed over the years, despite many changes in management (see above) partly owing to more patients being elderly. Early endoscopy has not so far reduced the mortality, although bleeding episodes are reduced.
Acute lower gastrointestinal bleeding
Massive bleeding from the lower gastrointestinal tract is rare. On the other hand, small bleeds from haemorrhoids occur very commonly. Massive bleeding is usually due to diverticular disease or ischaemic colitis and may require urgent resuscitation. Surgery is rarely required as bleeding usually stops spontaneously. The causes of lower gastrointestinal bleeding are shown.
Resuscitation when required.
Make diagnosis using the following investigations as appropriate:
• Rectal examination, e.g. carcinoma
• Proctoscopy, e.g. haemorrhoids
• Sigmoidoscopy, e.g. inflammatory bowel disease
• Barium enema-any mucosal lesion
• Colonoscopy-diagnosis and removal of polyps
• Angiography-vascular abnormality, e.g. angiodysplasia
Treatment. Individual lesions are treated as appropriate.
Chronic gastrointestinal bleeding
Patients with chronic bleeding usually present with iron deficiency anaemia.
Chronic blood loss producing anaemia in all men and all women after the menopause is always due to bleeding from the gastrointestinal tract. Occult blood tests are not, therefore, necessary.
Chronic blood loss can occur with any lesion of the gastrointestinal tract that produces acute bleeding. In addition a Meckel’s diverticulum and carcinoma of the caecum may present with an iron deficiency anaemia. It should be remembered that, worldwide, hookworm is the commonest cause of chronic gastrointestinal blood loss.
Careful history and examination may indicate the most likely site of the bleeding, but if no clue is available it is usual to investigate both the upper and lower gastrointestinal tract endoscopically at the same session (‘top and tail’).
For practical reasons an upper gastrointestinal endoscopy is performed first as this takes minutes only. If no lesion is found this is followed by a colonoscopy as a possible lesion can be removed or biopsied. A barium enema is performed if colonoscopy is unavailable. A small bowel follow-through is the next investigation but the diagnostic yield is very low. Following a negative investigation, an angiogram may show up the site of bleeding, particularly when acute bleeding is occurring. Occasionally intravenous technetium-labelled colloid may be used to demonstrate the bleeding site in a Meckel’s diverticulum. Endoscopes to visualize the whole of the small bowel (enteroscopy) are available at specialist centres.