From the Guidelines
Internal bleeding should be suspected in an anemic person when they exhibit signs of unexplained fatigue, weakness, pale skin, rapid heart rate, shortness of breath, and dizziness alongside dropping hemoglobin levels, particularly if they have GI-related symptoms or risk factors for bleeding, as indicated by the British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults 1. When evaluating a patient with anemia, it is crucial to consider the potential causes of iron deficiency, including occult blood loss, which can be compounded by concurrent antiplatelet/anticoagulant therapy, especially in the elderly population 1. The diagnosis of internal bleeding typically involves a combination of:
- Blood tests, such as complete blood count and iron studies
- Stool tests for occult blood
- Imaging studies, like endoscopy, colonoscopy, CT scans, or MRIs to locate the bleeding source As suggested by the GI evaluation of iron deficiency anemia clinical decision support tool, diagnostic evaluation should be tailored to the patient's symptoms, and asymptomatic patients with iron deficiency anemia may require a different approach 1. Key warning signs that may indicate internal bleeding include:
- Black or bloody stool
- Vomiting blood
- Abdominal pain
- Unexplained bruising Rapid drops in hemoglobin or hematocrit, especially with hemodynamic instability, indicate active bleeding requiring immediate medical attention. It is essential to note that internal bleeding can occur throughout the digestive tract, in organs like the liver or spleen, or in body cavities following trauma, so thorough evaluation is necessary when anemia has no other clear cause, as emphasized by the British Society of Gastroenterology guidelines 1.
From the Research
Signs of Anemia and Potential Bleeding
- Anemia is a common condition that can be caused by various factors, including blood loss 2
- Patients with anemia may present with symptoms such as fatigue, weakness, and shortness of breath, or anemia may be an incidental finding on laboratory evaluation 2
- A thorough history and physical examination, as well as a complete blood cell count (CBC), are essential in evaluating anemia and determining its cause 2
Diagnostic Approach to Anemia with Potential Bleeding
- The diagnostic approach to anemia with iron deficiency without overt bleeding involves conducting serological celiac disease screening, performing bidirectional endoscopy (gastroscopy and colonoscopy), and investigating the small intestine if necessary 3
- Bidirectional endoscopy is not required in premenopausal women under 40 years of age, but should be considered in other patients with unexplained anemia and iron deficiency 3
- The reticulocyte count serves as a useful screen for hemolysis or blood loss, and testing for specific causes of anemia, such as iron panel and vitamin B12 levels, may also be necessary 4
Investigating the Gastrointestinal Tract for Bleeding
- Gastrointestinal blood loss is a primary cause of iron deficiency anemia in older adults, and bidirectional endoscopy is highly sensitive and specific in locating gastrointestinal lesions resulting in iron deficiency anemia 5
- Colonoscopy or barium enema may be more effective than gastroscopy in detecting malignancy among patients presenting with iron-deficiency anemia, with a higher diagnostic yield and better 5-year survival rates 6
- If neither colonoscopy nor esophagogastroduodenoscopy identifies a source of blood loss, observation and supplemental iron may be a safe course, but further evaluation is necessary if the patient fails to respond or becomes transfusion-dependent 5