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علاج نزيف الجهاز الهضمي
Gastrointestinal bleeding means blood escaping from anywhere along the digestive tract, from the oesophagus and stomach through the small intestine, colon and rectum. It is not a disease in itself but a symptom of a cause that must be found, and in most of its forms it is a medical emergency, because the volume of blood lost may not be obvious until pulse and blood pressure begin to change. The golden rule, therefore, is that any gastrointestinal bleeding is assessed immediately, never observed at home to see whether it will stop by itself. The appearance of the bleeding usually hints at its location: vomiting red blood or coffee-ground material, and black tarry foul-smelling stools, generally point to an upper source, while red blood mixed with or coating the stool suggests a lower one, with enough exceptions that the final judgement belongs to examination rather than to the patient. There is also occult bleeding, invisible to the eye, which shows up only as iron-deficiency anaemia with fatigue, pallor and breathlessness on exertion; this form is no less important, because it sometimes uncovers a silent ulcer or tumour. The causes are many and are determined by assessment: gastric or duodenal ulcer, oesophageal varices in people with liver disease, a mucosal tear after forceful vomiting, oesophagitis or gastritis, colonic polyps and tumours, diverticular disease, chronic inflammatory bowel disease, haemorrhoids and anal fissure, and vascular malformations. Blood thinners, anticoagulants and non-steroidal anti-inflammatory painkillers all raise the likelihood and severity of bleeding, which is why they are asked about in the first minute of assessment. Treatment proceeds along three parallel stages. First, stabilising the patient with intravenous fluids, monitoring of pulse and blood pressure, blood tests and transfusion when required. Second, locating and stopping the source, and the tool for this in most cases is upper endoscopy or colonoscopy, where bleeding is controlled with methods such as clips, thermal coagulation, injection therapy or banding of varices. Third, treating the underlying cause and preventing recurrence. In selected cases where endoscopy is insufficient, angiographic catheter techniques are used to stop the bleeding, or surgery is performed. One limit must be stated plainly: **stopping the bleeding is not the same as treating its cause**. Closing a bleeding ulcer does not remove your need to eradicate Helicobacter pylori or to stop the painkiller that caused it; banding oesophageal varices does not treat the liver disease that created them; and cauterising bleeding from a polyp does not replace completing the assessment of the colon. Without treating the cause, bleeding returns, often more heavily. A dangerous common assumption also needs correcting: black stools are not always due to an iron supplement or a particular food, and **that must never be assumed without assessment**. Equally, bleeding that appears to have stopped on its own does not close the file; it opens the search for the cause. And never stop a blood thinner or a cardiac medication on your own decision, tell your physician immediately and let them decide.
Blood pressure, pulse and level of consciousness are measured, an intravenous line is placed and fluids given, and blood is drawn for haemoglobin, clotting, liver and kidney function and blood group. The volume lost is judged clinically rather than by what the patient saw, and transfusion is given when needed before any procedure.
You are asked immediately about blood thinners, anticoagulants, aspirin and anti-inflammatory painkillers, and about liver disease and any history of ulcer or varices. This information determines how fast intervention must happen and whether your clotting needs correction before endoscopy, so no medicine or supplement should be withheld.
Upper endoscopy is performed when an upper source is suspected, or colonoscopy after suitable preparation when a lower source is likely, examining the lining for an ulcer, varices, a vascular malformation, a polyp or inflammation. The timing of endoscopy is set by how stable you are, not by a wish to have it sooner.
Bleeding is controlled during endoscopy using methods such as metal clips, thermal coagulation, local injection or variceal banding, depending on the source. In selected cases that do not respond, angiographic catheter embolisation of the feeding artery is used, or the patient is taken for urgent surgery.
Once bleeding is stopped, the part that prevents recurrence begins: eradicating Helicobacter pylori if present, stopping or replacing painkillers, treating liver disease and following up varices, completing assessment of the colon, correcting anaemia with iron, and restructuring blood-thinning therapy in coordination between your treating physician and your cardiologist.
If you see blood in your vomit or stool, go to the emergency department at once rather than waiting for a clinic appointment, and do not eat or drink until you have been assessed, because endoscopy may be urgent. Take your full medication list or the boxes themselves, especially blood thinners, anticoagulants, aspirin, anti-inflammatory painkillers, steroids and iron supplements. Tell the physician the colour of what you saw, roughly how much, how many times and when it first happened, along with any dizziness, fainting, palpitations or sweating. Mention liver disease, any previous ulcer, varices, earlier bleeding or gastrointestinal surgery, and your blood group if you know it. Do not stop any medicine yourself and do not take a new painkiller, and arrange for someone to accompany you.
After the bleeding is stopped you need a period of observation set by your physician, with follow-up blood counts and a gradual return to eating as directed. Complete the treatment of the cause in full, whether eradicating Helicobacter pylori and confirming it with a test, abstaining from irritant painkillers, or attending banding sessions for varices, because that is what prevents a second bleed. Finish the prescribed course of iron to correct anaemia and do not stop it because the fatigue has gone, and never restart or stop a blood thinner except on your physician's documented decision. **Go to the emergency department immediately if you vomit fresh blood or coffee-ground material, pass black tarry stools or red blood, feel dizzy, faint, have palpitations or cold sweats, become pale or increasingly breathless, develop severe abdominal pain, or run a fever after the procedure.** Do not ignore persistent fatigue after discharge, as it may signal continuing occult bleeding.
Assessment and stabilisation in the emergency department usually take from one hour to several hours depending on severity. The therapeutic endoscopy itself typically takes twenty to sixty minutes, and most patients need in-hospital observation for a day to several days according to the cause, the severity and the response.
Dr Mohammad Mahmoud Rashid is a consultant in gastroenterology, hepatology and endoscopy with British postgraduate qualifications. His clinical work covers live…
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