What Are the Most Common Causes of Small Intestine Bleeding?

Intestinal hemorrhage, also known as lower gastrointestinal bleeding, refers to bleeding from the jejunum, ileum, cecum, appendix, colon, and rectum below the flexor ligament, excluding bleeding from hemorrhoids and anal fissures, accounting for 20% of the entire gastrointestinal bleeding. It is a more common gastrointestinal bleeding disease in clinical practice. Acute lower gastrointestinal bleeding is mainly manifested as blood in the stool, which can be bright red, dark red or tar-like. Lower gastrointestinal bleeding can usually stop, but there are 10% to 15%. Lower gastrointestinal bleeding should be treated urgently. According to the amount and speed of bleeding, it is divided into acute bleeding, dominant bleeding and recessive bleeding. Acute bleeding is relatively large and requires urgent treatment; dominant and hidden bleeding are mostly chronic, concealed, and the amount of bleeding is small. You can easily complete various tests. The cause of most gastrointestinal bleeding can be determined by gastroscopy and / or colonoscopy, but the cause cannot be determined in 5% of patients.

Intestinal hemorrhage, also known as lower gastrointestinal bleeding, refers to bleeding from the jejunum, ileum, cecum, appendix, colon, and rectum below the flexor ligament, excluding bleeding from hemorrhoids and anal fissures, accounting for 20% of the entire digestive tract bleeding. It is a more common gastrointestinal bleeding disease in clinical practice. Acute lower gastrointestinal bleeding is mainly manifested as blood in the stool, which can be bright red, dark red or tar-like. Lower gastrointestinal bleeding can usually stop, but there are 10% to 15%. Lower gastrointestinal bleeding should be treated urgently. According to the amount and speed of bleeding, it is divided into acute bleeding, dominant bleeding and recessive bleeding. Acute bleeding is relatively large and requires urgent treatment; dominant and hidden bleeding are mostly chronic, concealed, and the amount of bleeding is small. You can easily complete various tests. The cause of most gastrointestinal bleeding can be determined by gastroscopy and / or colonoscopy, but the cause cannot be determined in 5% of patients.

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Lower gastrointestinal bleeding

Overview of intestinal bleeding

Intestinal hemorrhage, also known as lower gastrointestinal bleeding, refers to bleeding from the jejunum, ileum, cecum, appendix, colon, and rectum below the flexor ligament, excluding bleeding from hemorrhoids and anal fissures, accounting for 20% of the entire digestive tract bleeding. It is a more common gastrointestinal bleeding disease in clinical practice. Acute lower gastrointestinal bleeding is mainly manifested as blood in the stool, which can be bright red, dark red or tar-like. Lower gastrointestinal bleeding can usually stop, but there are 10% to 15%. Lower gastrointestinal bleeding should be treated urgently. According to the amount and speed of bleeding, it is divided into acute bleeding, dominant bleeding and recessive bleeding. Acute bleeding is relatively large and requires urgent treatment; dominant and hidden bleeding are mostly chronic, concealed, and the amount of bleeding is small. You can easily complete various tests. The cause of most gastrointestinal bleeding can be determined by gastroscopy and / or colonoscopy, but the cause cannot be determined in 5% of patients.

Causes of intestinal bleeding

The causes of lower gastrointestinal bleeding are mainly divided into primary intestinal diseases and systemic diseases involving the intestine:

1. Systemic diseases affect the intestinal tract: systemic diseases are mainly epidemic hemorrhagic fever, allergic purpura, etc., various poisoning, uremia, trauma and vitamin K deficiency. The most common causes of acute bleeding are diverticulosis and vascular dysplasia. The most common causes of chronic bleeding are hemorrhoids and tumors. The most common causes of bleeding are colon cancer and colon polyps, followed by intestinal inflammatory lesions.

2. There are four main types of primary intestinal diseases:

(1) Benign and malignant tumors and polyps, such as malignant lymphoma and leiomyosarcoma.

(2) Intestinal inflammation: radiation proctitis, bacterial dysentery, etc.

(3) Vascular diseases: such as telangiectasia and hemangiomas.

(4) Structural lesions of the intestinal wall: such as intestinal diverticulum, intestinal repetitive deformities, etc.

Intestinal bleeding diagnosis

Lower gastrointestinal bleeding has a more complex cause than upper gastrointestinal bleeding, the small intestine is not easy to check, and the diagnosis is relatively difficult. In the clinical etiology examination, the small intestine accounts for 20% to 33%, the large intestine accounts for 67% to 80%, and about 15% to 35. % The cause of lower gastrointestinal bleeding is not found, but according to the history, the color of the blood stool and auxiliary examination can generally make a diagnosis.

Intestinal bleeding history and physical examination

Polyps, intussusception, and acute hemorrhagic enteritis are more common in children and adolescents. Tumors and vascular lesions are common in middle-aged and elderly people. Blood drips after defecation, and those who are not confused with feces are more common in internal hemorrhoids, anal fissures, or rectal polyposis; stools are pus and bloody or blood feces are accompanied by mucus or pus feces. Bacteria, schistosomiasis, colorectal tuberculosis, and chronic colitis should be considered Colorectal tumors; blood in the stool with severe abdominal pain and shock, more common in hemorrhagic necrotic enteritis, mesenteric vascular embolism, intussusception; blood feces with abdominal mass, often tumors, intestinal tuberculosis, Crohn's disease and bowel Intussusception, blood in the stool with bleeding from the skin or other organs are mostly hematological diseases, acute infectious diseases, etc. At the same time, it is also necessary to pay attention to whether there is a history of taking aspirin or other nonsteroidal drugs, a history of abdominal radiotherapy, and a history of polyp removal Wait. Whether the abdomen is flat, with or without bowel type and asymmetric bulges, with or without tenderness and mass in the abdomen, and changes in the percussion tone and bowel sounds are of diagnostic value.

Judging the amount of bleeding is important for cases of lower gastrointestinal bleeding, and it is important to determine early whether it is acute major bleeding, dominant bleeding or occult bleeding in order to choose the next examination.

Acute bleeding should be considered in the following situations:

(1) The amount of blood feces can reach 200 ~ 300mL each time.

(2) Those whose blood transfusion exceeds 800 mL within 12 hours and still cannot keep blood pressure stable.

(3) Those with shock signs appear early.

Differential diagnosis of intestinal bleeding

The diagnosis of lower gastrointestinal bleeding should be distinguished from upper gastrointestinal bleeding. The patient's history and signs are supplemented by endoscopy to observe the amount of bleeding, the bleeding site, explore its cause and location, and finally form a diagnosis. Upper gastrointestinal bleeding is often manifested as vomiting or vomiting coffee, and the above abdominal symptoms are mainly. The gastric tube can suck bleeding fluid, which is an effective method to distinguish from lower gastrointestinal bleeding. Then, the amount of bleeding is estimated. Gastrointestinal bleeding is 5mL / d. Only the occult blood test is positive. The color of stool is unchanged. The amount of bleeding can be seen in 50 ~ 100mL per day. Black stool or tar is bleeding from the upper digestive tract or small intestine, dark red is above the transverse colon, and bright red is below the transverse colon. Although the quantitative indicators of major hemorrhage are not uniform at present, it can be determined by referring to the following data: adult bleeding volume 1000mL / d, daily blood loss 25% of total circulating blood volume, systolic blood pressure 80mmHg, and bleeding volume per hour 80mL , Hb80g / L.

Intestinal bleeding auxiliary examination

1. Emergency or elective colonoscopy: Emergency or elective colonoscopy is the clinically preferred method. Although the optimal examination time has not been determined in clinical examination, many related literatures have shown that the positive diagnosis rate of endoscopy within 24 hours after bleeding is as high as about 4%. Clinical studies have shown that more than two-thirds of the lower gastrointestinal bleeding is caused by the large intestine, so it can be inserted 20 to 30 at the end of the ileum, and given treatment at the same time as the examination, such as polyp removal, ligation hemostasis, high frequency electrocoagulation hemostasis, etc. . Intraoperative enteroscopy: the cause of lower gastrointestinal bleeding cannot be determined through various examinations, no bleeding lesions are found with the naked eye during surgery, and multiple or multiple lesions cannot be determined. Intraoperative enteroscopy can be used to further determine Preoperative examination showed lesions.

2. Enteroscopy: Enteroscopy (jejunoscopy) and capsule endoscopy are mainly used for enteroscopy. Propulsive enteroscopy is also called jejunoscopy. There is clinical literature showing that the accuracy of clinical diagnosis of enteroscopy is as high as 87.5%, which has a good application space. Capsule endoscopy can detect the entire small intestinal mucosa. It has been widely used abroad, with a diagnosis rate of 58% ~ 86%, but it is a little high in cost. Therefore, it will take some time to be widely applied in China.

3. Selective arteriography: When the bleeding rate is 0.5 ~ 1.0mL / min (750 ~ 1500mL / d), the bleeding signs can accurately determine whether there is active bleeding at the bleeding site, especially in the face of large bleeding In some cases, arteriography has high diagnostic value for intestinal wall vascular malformations, small intestinal diverticulum, and tumors, and can identify the bleeding site. In clinical treatment, artificial emboli can be injected with high selectivity to stop bleeding, with a success rate of 44% to 88%, or indwelling catheters can be continuously infused with vasoconstrictors or growth hormone analogs to stop bleeding.

4. Radionuclide scanning: Radionuclide scanning nuclide () marks red blood cells and is injected intravenously. When active bleeding (0.1 ~ 0.5mL / min), the positive rate of bleeding site is 51%, 99mTc2 sulfur colloid or 99mTc2 plant The imaging of lower gastrointestinal bleeding with sodium can show a diverticulum (mickle diverticulum) with gastric mucosal acid secretion function. In clinical application, its sensitivity is very strong, a small amount of bleeding can be detected, non-invasive, and no side effects, but at the same time its positive rate is not as high as angiography, can not be accurately located, often require further angiography to be clear.

5. Small bowel barium perfusion examination: CT, magnetic resonance (MRI) and small bowel angiography can be intubated to the proximal small intestine, and barium is injected to observe the small intestine through dynamic perspective. Gas can be injected at the same time to enhance the contrast effect. The diagnosis rate is 10%. ~ 20%, mainly used in patients with chronic bleeding, but the detection rate of superficial, flat, small or submucosal lesions is low. CT, MRI, and small bowel angiography not only visualize the bowel cavity, but also observe changes in the structure of the bowel wall. However, there are few clinical data and it is a small sample study. Its clinical value needs further verification.

Intestinal bleeding treatment

Medical treatment

Mainly by fasting, gastrointestinal decompression, oxygen absorption, infusion, blood transfusion, rescue shock and other means. Hemostasis uses 6-aminocaproic acid, tranexamic acid, stasis hemostasis, hemostatic and so on. Posterior pituitary (small dose) 20U + normal saline or glucose solution, 500mL ivgtt, 20 drops / min, clinical studies have said that the effective rate is as high as 80% ^[1] Somatostatin reduces portal pressure and suppresses intestinal fluid secretion. Oral and enema for hemostatic drugs use thrombin, norepinephrine, smecta, Menggs solution, etc.

Surgical treatment

Laparotomy is the main method. If the lesion is not found after auxiliary examination, laparotomy is required. The purpose of surgery is to remove lesions or suspected malignant lesions that are still bleeding or repeatedly bleeding through conservative medical treatment. For children, precise positioning should be performed during surgery, and the shorter intestine segment is better to prevent postoperative malnutrition. Arterial ligation is mainly ligation of the inferior mesenteric artery, superior rectal artery, or internal iliac artery. It can establish collateral circulation, generally does not cause intestinal necrosis, and has high safety. Its indication is that the colon and rectal lesions are extensive during operation. Unstoppable bleeding ^[2] .

Multidisciplinary close cooperation

Gastrointestinal bleeding is a clinical emergency. Timely and effective diagnosis and treatment can save patients' lives. The diagnosis and treatment of gastrointestinal bleeding involves multiple clinical disciplines and requires the close collaboration of experienced emergency department, gastroenterology, surgery and radiology interventional physicians. The author s hospital opened a through train for gastrointestinal bleeding 24 hours. Patients with gastrointestinal bleeding went to the emergency department. The emergency physician immediately evaluated the condition and started resuscitation treatment. Second-line doctors in the department of gastroenterology arrived at the scene to participate in the rescue as soon as possible. Endoscopic hemostasis treatment. Endoscopic-negative patients or patients who need surgery should be called by the second-line department of gastroenterology to call a surgical or radiology interventionist. After the opening of the "through train" for several years, the success rate of hemostasis of gastrointestinal bleeding has increased significantly, and the length of hospital stay has been significantly reduced. Varicose gastrointestinal bleeding maintains zero fatality. Conditional hospitals should have procedures in place to save the lives of more patients.