From the Guidelines
Internal bleeding from gastrointestinal sources, such as hereditary hemorrhagic telangiectasia (HHT), can cause low hemoglobin, hematocrit, and red blood cell counts, collectively known as anemia. According to a study published in 2021 1, GI bleeding develops in approximately 30% of patients with HHT and is caused by mucosal telangiectasias in the stomach, small bowel, and/or colon. This condition can lead to significant anemia, with patients requiring iron infusion or red cell transfusion.
Some common sources of internal bleeding that can cause anemia include:
- Gastrointestinal bleeding (such as from peptic ulcers, gastritis, esophageal varices, or colorectal cancer)
- Genitourinary bleeding (including heavy menstrual bleeding or kidney injuries)
- Trauma-related internal hemorrhage (like splenic rupture or liver lacerations)
- Ruptured aneurysms
- Bleeding disorders
- Complications from medications like anticoagulants
These conditions reduce blood values because blood loss depletes the body's red blood cell supply faster than it can be replenished. Symptoms may include fatigue, weakness, dizziness, shortness of breath, and in severe cases, shock. Diagnosis typically involves blood tests, imaging studies, and possibly endoscopy. Treatment depends on the bleeding source but may include blood transfusions, medication to stop bleeding, or surgical intervention.
In patients with acute upper gastrointestinal bleeding, the decision to transfuse blood should be based on the patient's hemodynamic status, underlying condition, and markers of tissue hypoxia, rather than a fixed hemoglobin level 1. However, the most recent and highest quality study recommends systemic therapies, such as bevacizumab, for patients with moderate or severe GI bleeding, which can improve mean hemoglobin levels by 3-4 g/dL 1. Prompt medical attention is essential as severe internal bleeding can be life-threatening.
From the Research
Internal Bleeding Causes
Internal bleeding can cause low hemoglobin, hematocrit, and hemoglobin levels due to various reasons. Some of the possible causes include:
- Gastrointestinal bleeding, which can be acute, chronic, or occult 2
- Upper gastrointestinal bleeding, defined as hemorrhage from the mouth to the ligament of Treitz, can cause signs and symptoms such as abdominal pain, lightheadedness, dizziness, syncope, hematemesis, and melena 3
- Peptic ulcer bleeding, gastritis, esophagitis, variceal bleeding, Mallory-Weiss syndrome, and cancer are some of the causes of upper GI bleeding 3
Laboratory Tests and Treatment
Laboratory tests such as complete blood count, basic metabolic panel, coagulation panel, liver tests, and type and crossmatch are necessary to diagnose and manage internal bleeding 3
- A bolus of normal saline or lactated Ringer solution should be rapidly infused to correct hypovolemia and to maintain blood pressure, and blood should be transfused when hemoglobin is less than 7 g per dL 3
- Clinical prediction guides, such as the Glasgow-Blatchford bleeding score, are necessary for upper GI bleeding risk stratification and to determine therapy 3
- Proton pump inhibitors should be initiated upon presentation with upper GI bleeding, and high-dose proton pump inhibitor treatment is recommended for the first 72 hours post-endoscopy 3