II. Diagnosis

  1. Fecal Occult Blood positive or
  2. Iron Deficiency Anemia without other source of iron loss

III. Causes

  1. See Occult Gastrointestinal Bleeding Causes
  2. More than one bleeding source identified in up to 17% of cases
  3. Upper Gastrintestinal bleeding source (29-56%)
  4. Lower Gastrointestinal Bleeding source (20-30%)
  5. Small Intestinal Bleeding source
    1. Typically Obscure Gastrointestinal Bleeding in which no source is identified (29-52%)
    2. A large percentage of Obscure Gastrointestinal Bleeding are likely secondary to small bowel Gastrointestinal Bleeding

IV. History

  1. Past History
    1. Gastrointestinal Bleeding History
    2. Abdominal Surgery
    3. Gastric Bypass Surgery
      1. Risk of Iron Deficiency Anemia
    4. Liver disease
      1. Risk of Portal Hypertension and Esophageal Varices
    5. Extra-intestinal sources of bleeding
      1. Menorrhagia
      2. Epistaxis
      3. Hematuria
  2. Family History Gastrointestinal Bleeding
    1. Hereditary Hemorrhagic Telangiectasia
      1. Vascular lesions on lips, Tongue and palms
    2. Blue Rubber Bleb Nevus Syndrome
      1. Venous malformation of gastrointestinal tract, skin and soft tissue
  3. Red Flags
    1. Unintentional Weight Loss
  4. Focal Symptoms
    1. Abdominal Pain
  5. Medications
    1. NSAIDs
    2. Anticoagulant
      1. Warfarin
      2. Pradaxa
    3. Antiplatelet Agents
      1. Aspirin
      2. Plavix

V. Exam: Specific findings in syndromes predisposing to Gastrointestinal Bleeding

  1. Gluten Sensitive Enteropathy
    1. Dermatitis Herpetiformis
  2. Crohn's Disease
    1. Erythema Nodosum
  3. Plummer-Vinson Syndrome
    1. Spoon shaped nails
  4. Ehler-Danlos Syndrome
    1. Hyperextensible joints
  5. Peutz-Jeghers Syndrome
    1. Lips and mouth freckling

VI. Approach

  1. Overt or visible bleeding
    1. See Gastrointestinal Bleeding
  2. Step 1: Upper and Lower endoscopy
    1. Upper and lower endoscopy identifies 48 to 71% of sources
    2. Indications to start with lower endoscopy
      1. Age over 50 years
    3. Indications to start with upper endoscopy
      1. Age under 50 years
      2. Significant NSAID use
      3. Alcohol Abuse
  3. Step 2: Approach to negative endoscopy
    1. Active, overt bleeding
      1. Tagged Red Cell Scan (helpful in brisk bleeding) or
      2. Angiography
    2. Recurrent intermittent bleeding
      1. Repeat endoscopy identifies missed lesions in 35% of cases
      2. Consider CT enterography
  4. Step 3: Small Bowel evaluation
    1. Evaluate Small Bowel for source if endoscopy does not reveal source
    2. Start with Capsule Endoscopy
    3. Consider push enteroscopy, deep enteroscopy or surgery if Capsule Endoscopy negative

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