Author’s note: This is the 8th diary in a series that I will post monthly, on medical topics related to emergency care. If you want to check out the first diary in the series, you can find it here, on the topic of insider tips to improve your ER visit, and the second one here, on the topic of heart attacks. Some of these diaries will focus on the medical system or process, and some will be disease-specific. My goal, as your friendly neighborhood ER doc to the Daily Kos community, is to provide useful information for this community to stay healthy and get the best results from our medical system. I hope you find it helpful!
One day, you notice that your bowel movement is streaked with blood. This has never happened before, and you are justifiably a little freaked out. But you steady your nerves, and say — “well, I feel fine and nothing hurts. Let’s see if that happens again”. But then the next day it happens again, but now there is more blood. And now you feel a little dizzy and fatigued. At what point is this an emergency? What are the causes? Do you need to call an ambulance?
Gastrointestinal bleeding, or GI bleeding, is never normal — but a fairly common problem that people face at some point in their life. While I suspect most of us who experience bleeding in our bowel movements (or vomiting blood) are terrified that we have cancer, there are many causes of GI bleeding — and most are not cancer. Some causes are not particularly serious, and some causes are life-threatening. The goal of today’s diary is to give you some of the basics, and some information on when you need to go to the ER, versus when you can safely wait to call your physician during office hours to discuss the problem.
The basics: The GI system.
The GI tract starts at the mouth and ends at the anus. In basic order, the GI tract is composed of mouth-->esophagus-->stomach-->small bowel-->large bowel-->rectum-->anus. It is convenient to think of the GI tract in two domains — the “upper GI tract” and the “lower GI tract”. This is indeed an important medical distinction for a number of reasons, which we will address shortly. The upper GI tract starts at the mouth and ends with the first portion of the small bowel; the lower GI tract starts with the second part of the small bowel and ends at the anus. Pretty much the entire GI tract is lined on the inside with a thin layer of tissue that is exposed to the contents of your food as it digests, as well as stomach acid and digestive enzymes — I have always found it remarkable that this layer can stay intact under such conditions! This layer of tissue is paper thin, and very vascular (it contains lots of blood vessels), since it is constantly repairing, growing, and absorbing nutrients.
Bleeding can occur at any point in the GI tract, but medical providers characterize bleeding as either upper GI bleeding (often abbreviated in medical charts as UGIB) or lower GI bleeding (LGIB), based on the source of the blood. Vomiting blood is generally a sign of upper GI bleeding, and pooping blood is generally a sign of lower GI bleeding.
An important point about GI bleeding that is crucial to know — it is not always bright red, but sometimes black. When blood sits in stomach acid, or spends a longer period of time in the GI tract, it essentially “curdles” and gets partially digested — this blood is black in color. When one vomits old curdled blood, it comes up as black granules, in the medical lingo this is often referred to as “coffee ground emesis” (emesis means vomiting), because it really does look like coffee grounds. When one poops curdled blood, it comes out like black or maroon paste, which is known in the lingo as “melena”. So if you have black bowel movements, especially if they are a bit loose, this is often a sign of slow chronic GI bleeding. Another key point about GI bleeding — it generally appears like more blood than it actually is. When it’s YOUR blood coming out, it makes sense that it seems like a lot of blood — but your body has 4 liters of blood, more or less — and even a very bloody-appearing bowel movement may only contain 20-30 ml of blood. So in most cases, take a deep breath. Medical attention is required, but no need for immediate panic.
Upper GI bleeding: causes
If you find yourself vomiting up red blood (or vomiting coffee ground emesis), there are a number of frequent causes that are worth considering. Probably the most common are stomach ulcers, also known as peptic ulcer disease (PUD). Stomach ulcers, or its milder form, stomach lining irritation known as gastritis, are very common. One of the most frequent activities that can worsen this problem is overuse of non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen or naproxen. So, one of the best ways to help prevent stomach ulcers, and stomach ulcer bleeding, is don’t overdo it with NSAIDs — and always take them with food, when possible. Another key prevention for stomach ulcers is the use of medications to manage gastric acid, medicines such as pepcid or prilosec, generally very safe drugs that are used by many people with “heartburn”. Another common cause of upper GI bleeding is trauma to the esophagus from vigorous vomiting — this can happen after you have a bad GI stomach flu, food poisoning or too much alcohol with vomiting. So: if you are vomiting a bunch from a known cause, and then you start to notice red streaks in the vomit, almost certainly the cause is mild esophageal injury — known as a Mallory-Weiss tear. In the vast majority of cases, not a big deal and will heal just fine. So: small amount of blood in vomit, if you have been vomiting a bunch, will almost always get better on its own. Best to drink lots of water, eat only bland foods for a day or two, get some rest, and see if it settles down over 24 hours before you rush to the ER. A more serious cause of upper GI bleeding are esophageal varices, which are big dilated veins in the esophagus that can bleed copiously — but these really only occur in patients with advanced liver disease (cirrhosis), so this won’t be a surprise thing that just happens one day. Finally, upper GI bleeding can be a sign of esophageal or gastric cancer — so if you have bloody vomiting that persists for days, you definitely need to be checked out by a physician.
The most important test to assess upper GI bleeding is an endoscopy — a long tube with a camera is inserted through the mouth and down to the stomach, so that a direct visual assessment of the GI tract can be made. This is a routine outpatient test, done by gastroenterologists. Key pro tip: this is not performed by ER docs, and only done in the ER on rare occasions for really bad bloody vomiting — so don’t expect an endoscopy in the ER. I wish we could do them, but current certifications aren’t structured to allow it.
Another key pro tip: if you poop black material (melena), this often is a sign of an upper GI bleed, even though it’s coming out the bottom end.
Lower GI bleeding: causes
If you notice bright red blood in your poop, it may be a lower GI bleed. A very common cause is diverticulosis, a condition of abnormal pouches that form in the wall of the colon and irritate nearby veins in the lining of the colon. It is more common as we age, so it is very unusual for someone in their 30s or 40s, say, to have diverticulosis; it is a condition that is much more common in the 50s — 80s. Diverticulosis, when it gets bad, sometimes requires surgery to remove part of the colon — so following up with a gastroenterologist is important. Another common cause is bleeding colon polyps. Polyps are abnormal growth in the wall of the colon (sometimes they are pre-cancerous), that can bleed from veins in the polyps themselves. This problem is solved by colonoscopy, in which a tube with a camera is inserted in the rectum and snaked up the colon to the problem spot — at which point a polyp can be snipped off via the colonoscopy equipment. A third, and very common cause of blood in the stool, are internal hemorrhoids, abnormal veins in the rectum and anus that can bleed and sometimes are very painful. This is an important distinction, because polyps and diverticular bleeds typically are not painful, but hemorrhoids typically are. Another cause of lower GI bleeding is inflammatory bowel disease (Crohn’s disease or ulcerative colitis) — these are chronic autoimmune conditions that are not very common in the general population. Then, of course, lower GI bleeding can be a sign of colon cancer — which is less common than the non-cancerous causes. So: lower GI bleeding can be serious, but the non-cancer causes are much more common than cancer — so bleeding doesn’t mean you have cancer. You just need to be evaluated.
So, I’m bleeding: do I need to go to the ER?
First, it is important to state that GI bleeding is never normal and always needs evaluation at some point. Maybe not right away, but within days to weeks. The main life-threatening risk of bleeding, of course, is losing too much blood — which is very uncommon, but certainly can happen. Think of your blood volume in the body as a tank of gas that is almost always full. When you bleed, your tank level is dropping — most GI bleeds, at their worst, might bring you down to an 80% full tank or 60% full tank. When you start to get below 75% full, often symptoms occur that would be the key triggers for calling 911 or getting a ride to the ER. These would be signs of anemia (too little blood in the tank) — feeling dizzy, fatigued, sweaty, or having a racing heart rate (often felt as “palpitations” or weird thumping in your chest). If you have blood in your poop, but you feel generally fine otherwise (no dizziness, weakness, no passing out, etc) — you don’t need to immediately rush to the ER at 10 PM, for example. In 95% of cases, this can wait until the next day or a doctor’s office visit within a few days. That said, if it’s a lot of blood (I know, that’s subjective, I wish I could give a better answer), probably better safe than sorry — an ER visit within 12-24 hours is very reasonable. But your primary physician might be a better place to go if the bleeding doesn’t seem to be too much. The reason why this is important: in most cases of mild bleeding, the ER won’t do much to diagnose you, since you really need an endoscopy or colonoscopy, performed by a gastroenterologist on an outpatient, non-emergency basis. If the bleeding is copious, or if you DO get dizzy, weak or pass out — that’s definitely the time to call 911 and get to the ER — you might need to “fill the tank” with a blood transfusion if you have lost too much blood, which again is very uncommon.
If you have cirrhosis (hopefully few readers of this diary have cirrhosis) and you vomit blood — that is a special situation. You need to go the ER right away, as it can be serious. This is one of the many reasons why alcohol abuse is so deadly — it leads to cirrhosis, which can lead to life-threatening bleeding in the esophagus.
If you do go to an ER with GI bleeding of unclear cause, the key thing the ER team will try to determine is whether you are having an upper GI bleed or lower GI bleed. The ER team will check your blood count (complete blood count, or CBC, is the key blood test). If you are not anemic, and your evaluation is generally unrevealing, you will likely be sent home with follow-up instructions to see a gastroenterologist for endoscopy or colonoscopy. Very few patients with GI bleeding get hospitalized, although some are kept for 12-24 hours for “observation”, to check blood counts a few times to make sure the tank level isn’t dropping quickly, so to speak. In some cases, the ER team might order a CT scan of your abdomen to assess for more unusual causes of bleeding. If they have a suspicion for upper GI bleeding from stomach ulceration, they might prescribe pepcid, prilosec, protonix or another medication to suppress stomach acid. If they have think you have hemorrhoids, they might prescribe a stool softener, such as colace. If you do seek medical attention in an ER, here’s a pro-tip: go to the ER that is linked to your regular medical care, so that they can look up your old blood tests in the computer. This is key so that the ER staff can see your last CBC test as a “baseline” so they can compare with current testing and see if your tank level has dropped. Also, like any ER visit, make sure to bring your list of medications and be prepared to tell the staff about any medical problems you might have. Always keep a list of your medications on your person (in your wallet, purse, smartphone), this is hugely helpful for an ER evaluation.
A key note about cancer screening and prevention.
While lower GI bleeding is not commonly colon cancer, the reverse is true — colon cancer commonly bleeds. SO: if you have any bleeding in your bowel movements, especially if you are above a “certain age” (say, above 40), you definitely should get evaluated for a possible colonoscopy. Early colon cancer (or precancerous polyps) can be treated and CURED. Late colon cancer is, well, a much bigger problem. If you are 45 or older, you need to get a routine colonoscopy at least once every 10 years. Routine screening colonoscopy is a crucial, safe and very cost-effective way to catch early colon polyps and cancers that can be cured. I am certain that some readers of this diary today are over 50, and have been procrastinating about getting a colonoscopy. Please, do it — it can be life-saving. I certainly understand that some of you have not had one because of insurance problems; I sympathize with your position. I wish fervently for a single-payer government health care program, so that we can have universal preventative care that would include mammograms, colonoscopies and other cancer screenings. So to end on a political note, that is yet one more reason why the 2020 election is so important — better and broader healthcare coverage = early detection of cancer and saving lives.
I will check back frequently today to discuss this topic and answer any questions — so leave a comment below and let’s chat. The ER doctor is “in”!