Gastrointestinal Bleeding: Symptoms, Complaints, Signs

The following symptoms and complaints may occur together with gastrointestinal bleeding (gastrointestinal hemorrhage):

Leading symptoms

  • Hematemesis (vomiting of blood; coffee grounds vomiting); if blood comes into contact with gastric acid (e.g., gastric or duodenal bleeding/duodenal bleeding): coffee grounds-like vomiting of blood
  • Melena (tarry stools) – stool abnormally black in color due to blood admixtures, usually also foul-smelling and shiny; occurs due to bacterial breakdown of blood in the lower intestinal segments (is deposited about 6 to 10 hours after the onset of bleeding); occurrence from a daily blood loss of 50-100 ml.
  • Hematochezia (red blood stool or rectal bleeding) – refers to a form of intestinal bleeding or massive bleeding distal to the pylorus (“after the stomach gate”) with the appearance of fresh blood in the stool

Associated symptoms

  • Loss of consciousness
  • Pallor (anemia)
  • Shock symptomatology (hypotension/low blood pressure, tachycardia (heartbeat too fast: > 100 beats per minute)):
    • Inconspicuous circulatory parameters in supine and upright positions → loss of less than 10% of intravascular (“in the vessels“) blood volume.
    • Orthostatic tachycardia and hypotension (regulatory disturbance of pulse rate ↑ and blood pressure ↑ occurring when changing to the upright position) → loss of at least 10-20% of intravascular blood volume
    • Hypotension in supine patients → loss of 20-25% of intravascular blood volume.
  • Vertigo (dizziness)
  • Nausea (nausea)/vomiting

Differential diagnosis: upper gastrointestinal bleeding (OGIB) versus lower gastrointestinal bleeding (UGIB).

Symptoms OGIB UGIB
Hematemesis (vomiting of blood) +
Hematochezia (red blood stool or rectal bleeding) (+) 1 +
Meläna (tarry stools) + (+) 2

1 Only in case of massive bleeding 2 In case of sluggish intestinal transit.

Warning signs (red flags) [upper gastrointestinal bleeding/gastrointestinal hemorrhage]

  • Syncope (momentary loss of consciousness).
  • Blood undiscolored bright red and foamy → think of: pulmonary hemorrhage (pulmonary hemorrhage); auscultation (listening) to the lungs: usually moist rales (RG).
  • Hematemesis (vomiting blood) + ascites (abdominal dropsy) + jaundice (jaundice) → indications of possible bleeding from portal-venous collaterals in liver cirrhosis (irreversible damage to the liver, leading to a gradual connective tissue remodeling of the liver with restriction of liver function).
  • Melena (tarry stools) and hematemesis (vomiting of blood) → indicates upper intestinal bleeding

Warning signs (red flags) [anorectal bleeding/terminal intestinal bleeding]

  • Medical history:
    • Younger patients → think: inflammatory bowel disease (IBD), polyps.
    • Older patients → think of: Diverticular and polyp hemorrhage, carcinoma, CED, proctitis (rectal inflammation).
    • Colonoscopy with polyectomy (colonoscopy with removal of polyps).
    • Rectal cancer (rectal cancer)
  • Syncope (collapse)
  • Peranal (“through the anus“) discharge of larger amounts of blood or coagula (clotted blood).
  • Continuous medication: see below drug side effects: “bleeding due to medication”.