Differential diagnosis

With wide use of gastroduodenoscopy the question of differential diagnosis of bleeding is less significant. However such a problem arises due to impossibility to use this method of examination when the general condition of patient is bad or taking into account other reasons. Differential diagnosis is conducted in bleeding of nonulcer origin, which can arise in different parts of digestive tract.

For bleeding from the varicose veins of esophagus in patients with portal hypertension with liver cirrhosis. This type of bleeding is massive and leading to considerable haemorrhage. Vomiting of fresh blood, expressed tachycardia, falling of arterial pressure are observed. In such patients it is possible to find the signs of cirrhosis of liver and portal hypertension.

The cancer of stomach in the destruction stage can be also compli­cated by bleeding. Such bleeding often are not massive, and chronic character is carried mostly with gradual growth of anaemia. Worsening of the general condition of patient, loss of weight, decreasing of appetite and waiver of meat are inherent in this pathology.

The gastric bleeding can be related to the diseases of the cardio­ vascular system (atherosclerosis, hypertensive disease), This is mainly seen in the older people.

Other diseases to be differenciated from ulcer bleeding are: the Mallory-Weiss syndrome, benign tumours of stomach and duodenum (more frequent leiomyoma), haemorrhagic gastritis, acute (stress) erosive defects of stomach, arteriovenous fistula of mucosa.

Diagnosis program

1. Anamnesis and physical examination.

2. Digital examination of rectum.

3. FGDS.

4. Laboratory studies.

5. Other necessary instrumental examinations.

Laboratory studies

CBC is necessary to assess the level of blood loss. Where possible, having the patient’s previous results is useful to gauge the level of blood loss. CBC should be checked frequently (4–6 h.) during the first day.

Basic metabolic profile (BMP): The BMP is useful to evaluate for renal comorbidity; however, blood in the upper intestine can elevate the BUN level as well.

Measurement of coagulation parameters is necessary to assess for continued bleeding. Abnormalities should be corrected rapidly.

Prothrombin time/activated partial thromboplastin time.

Liver profile. The liver profile can identify hepatic comorbidity and suggest underlying liver disease.

Calcium level. A calcium level is useful to identify the patient with hyperparathyroidism as well as to monitor calcium in patients receiving multiple transfusions of citrated blood.

Gastrin level. A gastrin level can identify the rare patient with gastrinoma as the cause of peptic ulcer bleeding and multiple ulcers.

Imaging studies

Chest and abdominal radiographs should be ordered to exclude aspiration pneumonia, effusion, and esophageal perforation; abdominal scout and upright films should be ordered to exclude perforated organs and ileus.

Barium contrast studies are not usually helpful and can make endoscopic procedures more difficult (i.e., white barium obscuring the view) and dangerous (i.e., risk of aspiration).

CT scan and ultrasonography may be indicated to evaluate liver disease with cirrhosis, cholecystitis with haemorrhage, pancreatitis with pseudocyst and haemorrhage, aortoenteric fistula, and other unusual causes of upper gastrointestinal haemorrhage.

Nuclear medicine scans may be useful to determine the region of active haemorrhage.

Angiography may be useful if bleeding persists, and endoscopy fails to identify a bleeding site. As salvage therapy, embolization of the bleeding vessel can be as successful as emergent surgery in patients who have failed the second attempt of endoscopic therapy.

Procedures

Nasogastric lavage. This procedure may confirm recent bleeding (coffee ground appearance), possible active bleeding (red blood in the aspirate that does not clear), or a lack of blood in the stomach (active bleeding less likely but does not exclude an upper gastrointestinal lesion).

A nasogastric tube is an important diagnostic tool, and tube placement can reduce the patient’s need to vomit. Placement for diagnostic purposes is not contraindicated in patients with possible esophageal varices.

The characteristics of the nasogastric lavage fluid (e.g., red, coffee grounds, clear) and the stool (e.g., red, black, brown) can indicate the severity of the haemorrhage. Red blood with red stool is associated with an increased mortality rate from more active bleeding compared with negative aspirate findings with brown stool.