Internal Medicine

0521779407-08 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:47

614 Gastrointestinal Bleeding

■Dyspepsia may or may not be present

➣∼50% of patients >60 years have dyspepsia with bleeding

➣∼35% of patient <60 years have dyspepsia with bleeding

■More specific features for some entities: reflux/heartburn –

esophagitis; forceful emesis – Mallory-Weiss tear of GE junction; dys-

pepsia – peptic ulcers; weight loss/early satiety – neoplasms; NSAID

use – ulcers; known or suspected cirrhosis – varices

■Occasionally just symptoms of anemia – weakness, pallor, dyspnea

Physical Findings

■occasionally, epigastric tenderness (for ulcer disease), rarely epigas-

tric mass or hepatomegaly for neoplasms or cirrhosis

■Lower GI bleeding (usually bleeding from distal small bowel or colon)

History

■Grossly bloody stools (note: this may occasionally be from brisk

upper GI bleed) or normal stools mixed with blood

■Occasionally melena (especially from distal small bowel or right

colon)

■Weight loss, constipation, diarrhea, anorexia – with colon cancer

■Abdominal pain, cramps, diarrhea, fevers and arthralgias – with idio-

pathic inflammatory bowel disease

■Occasionally symptoms of anemia alone

Physical Findings

■palpable mass (colon cancer primary or hepatomegaly from metas-

tases) or tenderness in lower quadrants (colitis); remember that

diverticular bleeding is painless

■Occult GI bleeding

■No hematemesis, melena, hematochezia – the most common pre-

sentation

■Occasionally, episodes of hematemesis, melena &/or hematochezia

with repetitively negative evaluations

■Chronic iron deficiency anemia &/or stools (+) for occult blood

■Usually no symptoms other than those of anemia

Tests

Laboratory Tests: Anemia

■acute blood loss: associated with normal MCV and MCHC, and nor-

mal iron and ferritin stores