Several tests are done to help confirm the suspected diagnosis:
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Complete blood count (CBC), coagulation profile, and often other laboratory studies
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Nasogastric tube (NGT) for all but those with minimal rectal bleeding
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Upper endoscopy for suspected upper GI bleeding
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Colonoscopy for lower GI bleeding (unless clearly caused by hemorrhoids)
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Sometimes angiography for upper and lower GI bleeding
CBC
Nasogastric aspiration and lavage should be done in all patients with suspected upper GI bleeding (eg, hematemesis, coffee-ground emesis, melena, massive rectal bleeding). Bloody nasogastric aspirate indicates active upper GI bleeding, but about 10% of patients with upper GI bleeding have no blood in the nasogastric aspirate. Coffee-ground material indicates bleeding that is slow or stopped. If there is no sign of bleeding, and bile is returned, the NGT is removed; otherwise, it is left in place to monitor continuing or recurrent bleeding. Nonbloody, nonbilious return is considered a nondiagnostic aspirate.
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Upper endoscopy (examination of the esophagus, stomach, and duodenum) should be done for upper GI bleeding. Because endoscopy may be therapeutic as well as diagnostic, it should be done rapidly for significant bleeding but may be deferred for 24 hours if bleeding stops or is minimal. Upper GI barium x-rays have no role in acute bleeding, and the contrast used may obscure subsequent attempts at angiography.
Flexible sigmoidoscopy and anoscopy may be all that is required acutely for patients with symptoms typical of hemorrhoidal bleeding. All other patients with hematochezia should have colonoscopy,
Angiography may be used to localize the source if it cannot be visualized with colonoscopy and ongoing bleeding is sufficiently rapid (> 0.5 to 1 mL/minute). Some angiographers first take a radionuclide scan to focus the examination, because angiography is less sensitive than the radionuclide scan. Angiography is useful in the diagnosis of upper as well as lower GI bleeding and permits certain therapeutic maneuvers (eg, embolization, vasoconstrictor infusion). The American Journal of Gastroenterology’s 2023 updated guidelines on management of patients with acute lower GI bleeding suggest CT angiography as the initial diagnostic test in patients with ongoing hemodynamically significant hematochezia. The decision of whether to proceed with endoscopy or angiography as the initial diagnostic or therapeutic test should be based on the patient’s clinical status and on the expertise and infrastructure available at the treating hospital.
Diagnosis of occult bleeding can be difficult, because heme-positive stools may result from bleeding anywhere in the GI tract. Endoscopy is the preferred method, with symptoms determining whether the upper or lower GI tract is examined first. Double-contrast barium enema and sigmoidoscopy can be used for the lower tract when colonoscopy is unavailable or the patient refuses it.
If the results of upper endoscopy and colonoscopy are negative and occult blood persists in the stool, an upper GI series with small-bowel follow-through, CT enterography, small-bowel endoscopy (enteroscopy), capsule endoscopy (which uses a small pill-like camera that is swallowed), technetium-labeled colloid or red blood cell (RBC) scan, and angiography should be considered. Capsule endoscopy is of limited value in an actively bleeding patient.
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