What are the symptoms of a gastrointestinal (GI) bleed?

Symptoms of Gastrointestinal Bleeding

The primary symptoms of GI bleeding include vomiting blood (hematemesis), vomiting altered black blood (coffee ground emesis), passage of black tarry stools (melena), and passage of bright red blood per rectum (hematochezia). 1

Upper GI Bleeding Presentations

Overt bleeding manifestations:

• Hematemesis - vomiting fresh red blood, indicating active upper GI bleeding 1
• Coffee ground vomiting - vomiting of altered black blood, suggesting slower or resolved upper GI bleeding 1
• Melena - passage of black tarry stools, the classic sign of upper GI bleeding 1

Severity indicators:

• Patients presenting with both hematemesis and melena have more severe bleeding than those with melena alone 1
• Hematemesis typically indicates a more proximal and active bleeding source 2

Lower GI Bleeding Presentations

Primary manifestation:

• Hematochezia - passage of bright red blood per rectum, usually indicating lower GI tract bleeding 1
• However, massive upper GI bleeding can occasionally present as hematochezia 1

Pain characteristics matter for diagnosis:

• Painless bleeding suggests diverticulosis or angiodysplasia 3
• Painful bleeding suggests inflammatory bowel disease, infectious colitis, or ischemic colitis 1, 3
• Abdominal pain, weight loss, fever, or diarrhea accompanying bleeding points toward inflammatory, infectious, or malignant lesions 1

Systemic Symptoms Indicating Hemodynamic Compromise

Critical warning signs:

• Pallor and fatigue 1
• Chest pain and palpitations 1
• Dyspnea and tachypnea 1
• Tachycardia (pulse >100 beats/min) 1
• Postural changes or syncope 1
• Lightheadedness and dizziness 2

Signs of Active or Recurrent Bleeding

Rebleeding is defined by:

• Fresh hematemesis and/or melena PLUS 1
• Development of shock (pulse >100 beats/min, systolic pressure <100 mm Hg) OR 1
• Fall in central venous pressure >5 mm Hg OR 1
• Reduction in hemoglobin >20 g/L over 24 hours 1

Occult Bleeding Presentations

Chronic or hidden bleeding may present as:

• Positive fecal occult blood test without visible bleeding 4, 5
• Iron deficiency anemia without obvious blood loss 5
• Recurrent episodes of overt bleeding with negative initial endoscopy 5

Common Pitfalls

Critical considerations:

• Approximately 10-15% of patients presenting with hematochezia actually have an upper GI source, so don't assume all bright red blood is from the lower tract 3
• Photographic documentation of bleeding (emesis basins, bedsheets, toilet bowls) can help confirm symptoms and guide remote management decisions 1, 6
• In elderly patients with cardiovascular disease, consider ischemic colitis when pain accompanies bleeding 3
• Recent antibiotic use should prompt consideration of Clostridioides difficile colitis 3
• History of pelvic radiation may indicate radiation proctitis occurring 9 months to 4 years post-treatment 1, 3

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