消化道出血是常见的临床表现之一，根据出血部位分为上消化道出血和下消化道出血。消化道出血具有多种病因，出血的严重程度也可大不相同，量少者无可见血，量多者可危及生命。根据病因不同，其诊治过程也可有明显的差异。

Gastrointestinal bleeding or gastrointestinal hemorrhage has a variety of causes, including bleeding from gastric/duodenal ulcer, esophageal varices,gastric leiomyoma/other tumor, polyp, angiodysplasia,hemorrhoids, blood clotting disorder and diverticular bleed.Upper gastrointestinal bleed usually refers to bleeding originating between the pharynx and the ligament of Treitz.Lower gastrointestinal bleed usually occurs in the large bowel(colon, rectum or anus).The bleeding can be acute or chronic, occult or frank, mild,moderate, severe or life-threatening.Clinical history and examination are important in the diagnosis, assessment and management of gastrointestinal bleeding.Amongst the routine questions, the clinical history should specifically inquire about the color of the stool [is it black/tarry indicating old/digested blood(melena),suggesting upper gastrointestinal bleed(however melena can occur in bleeding originating as distally as the ascending colon); or is it bright red indicating fresh blood, suggesting lower gastrointestinal bleed or torrential upper gastrointestinal bleed], vomitus [is it like coffee ground(old blood)or bright red(fresh bleed), both indicating upper gastrointestinal blood], common risk factors such as previous history of liver disease [consider bleeding from varices ± abnormal blood clotting(decreased coagulant factors ± platelets）], intake of steroids, non-steroidal anti-inflammatory drugs(NSAID),anticoagulants or antiplatelet agents(consider gastric/duodenal ulcer bleed, abnormal blood clotting).Physical examination should include a bedside assessment of the degree of blood loss, looking for signs of chronic liver disease, and a per-rectal digital examination to detect bleeding(fecal occult blood, fresh blood)or rectal lesion.A rough guide to estimating the % blood volume loss from symptoms/signs by the bedside is as follows: 15%(thirst/sweating), 20%(tachycardia without change in mean arterial pressure or central venous pressure), 30%(postural drop in blood pressure≥15mmHg), 40%(supine hypotension).Note that heart failure and drugs that blunt cardiac output(CO)or systemic vascular resistance(SVR)response pose a disproportionate risk of hypotension.The initial management includes resuscitation with oxygen, intravenous fluids and blood products.Adjunctive therapy may include a proton pump inhibitors,terlipressin/octreotide(variceal bleed).Prothrombin complex concentrate(if on warfarin/coumarin)should be considered for patients on warfarin.Vitamin K and fresh frozen plasma can be given(after blood sampling)without waiting for the clotting results if liver disease/variceal bleed is likely.Gastroscopy and colonoscopy are the main methods for identifying the source and cause of bleeding and carrying out therapeutic(endoscopic)maneuvers at the same time, where indicated.

D: Sit down, please.Could you tell me what is troubling you?

P: I feel fatigued during the past three months.And my stool has turned black in the last two days.

D: Do you vomit or feel nauseous?

P: No.

D: How often do you pass stool in a day?

P: Once or twice a day.

D: What does your stool look like apart from being black?

P: It is loose and looks fluffy.

D: Do you have any tummy(or abdominal)pain?

P: Yes.On the upper side of my belly.

D: What does the pain feel like?

P: It feels like some sort of burning and dull ache,especially after meals.

D: Does the pain go anywhere?

P: No.

D: How long have you had this pain?

P: Maybe on and off for two or three years, but not always.It’s never been this bad before.

D: Do you feel pain in the night?

P: Yes, it can happen in the middle of the night.

D: How is your appetite?

P: Not very good.I feel bloated most of the time.

D: Have you lost weight recently?

P: Yes, a lot recently.Maybe 5 kg or more.

D: Do you have a fever or night sweats?

P: No, I don’t think so.

D: Do you have any other medical conditions we have not talked about, including liver or heart disease?

P: No.

D: Have you ever seen a doctor about your problem before?

P: No, I haven’t.I just take a kind of pill called Talcid that I got from a friend.It used to work, but not any more.

D: What other medications are you taking?

P: Nothing on a regular basis.

D: How much alcohol do you drink on average in a week?

P: I don’t drink a lot, may be 1 glass of wine a week, but I smoke a lot.I am a taxi driver.

D: Do you or your family members have any special medical conditions, such as cancer, hepatitis,tuberculosis or other infectious disease?

P: No, I don’t think so.

D: Please may I examine you?

P: Yes, please doctor.

D: Ok.Please take off your clothes except you underwear and lie on the couch.You may use this blanket to cover yourself.Please call me when you are ready.

P: I am ready doctor.

D: Ok.

P: Doctor, is it serious?

D: Your heart rate and blood pressure are fine.However,we need to do more tests, including a blood test and gastroscopy.It might take a couple of days.Do you have any relatives with you?

P: My wife is here with me.

D: OK.I’ll show you how to arrange the tests.I will also prescribe some medications for you in the meantime.

P: Thank you!

P: Good morning, doctor.I feel better these days, but not completely back to normal yet.My stool is no longer black.Here are the results of my tests you asked me to do.I had my gastroscopy earlier this morning.

D: Let me take a look...There is an ulcer like lesion in the stomach.You also have anemia, by this I mean you are lacking in blood.

P: Do I need more tests or treatment?

D: A small piece of the lesion was taken during the gastroscopy, to allow examination under the microscope to see what the lesion in the stomach is.The result should be available in one week.

P: Is it cancer, doctor?

D: I don’t know yet.However, I think it may be worthwhile having a CT scan of your abdomen whilst waiting for the biopsy results.You can then bring the results of the CT scan and biopsy back to me in one week for discussion.

P: Will I need an operation?

D: It really is too early to say.It depends on the results of the biopsy and CT scan.If you prefer, you may consult a surgeon with these reports for a second opinion.

P: Ok, thank you doctor.

D: How can I help you?

P: I feel really fatigued these several days.I look pale and feel tired.My stool looks black, and is loose.

D: For how long?

P: About two days.

D: Do you feel pain anywhere?

P: I always feel pain in my tummy(pointing to upper abdomen), especially when I am hungry.

D: Does anything make it better?

P: I tend to eat some food which relives the pain.I have this symptom for several years, especially in the cold weather.

D: Have you ever seen a doctor about this before?

P: No, I haven’t.But I got some medicine from a pharmacist.

D: What medications are you taking?

P: I can’t remember but normally works.This time it has stopped working.

D: Do any of your relatives have similar problems?

P: I don’t think so.Actually, I am not very clear about that.

D: Do you have liver disease?

P: No.

D: Are you vomiting at all?

P: No.

D: Please may I examine you?

P: Ok, doctor.

D: Please could you take off your clothes except you underwear and lie on the couch.You may use this blanket to cover yourself.Please call me when you are ready.

P: OK.

P: I am ready doctor.

D: Ok.

D: I think you are bleeding from your stomach or duodenum because your stool has turned black.As a result, you are losing blood, which makes you look pale with low blood pressure and high heart rate.I recommend you be admitted to hospital for urgent treatment and further tests.

P: Will I need to stay in hospital for a long time?

D: Usually a few days, but may be longer depending on how you are and what we find out from the tests.If you agree to be admitted to hospital, please make an in-patient registration over there.

D: Do you feel better today?

P: Yes, of course.After transfusion, I feel much better.

D: Your hemoglobin was only 6g/dl, almost half the normal because of bleeding in your stomach or duodenum.

P: You are right doctor.I had a gastroscopy yesterday.The endoscopist told me that I was bleeding from a big ulcer in the duodenum.Luckily the bleeding had already stopped before the gastroscopy.Thank you very much doctor for helping me.

D: You are welcome.Have you opened your bowels today?

P: No, I don’t.I haven’t eaten anything since I came to the hospital.

D: You may start to eat and drink now.

P: Great, I am hungry! I have heard that Helicobacter infection can cause the condition I have.Do I have the infection?

D: Yes, the test was positive for the infection.I will give you a course of antibiotics to eradicate the bacteria.

P: Thank you very much, doctor!