Chapter 63 Evaluation of Gastrointestinal Bleeding James M. Richter Ambulatory patients frequently report gastrointestinal bleeding to the primary physician.

They may complain of melena (tarry black stools), hematochezia (bright red or maroon blood per rectum), or hematemesis (vomiting fresh or changed blood). Sometimes, gastrointestinal bleeding may be occult and evident only as a positive result on a screening test for fecal occult blood or as iron-deficiency anemia. Decisions regarding the nature and pace of the evaluation of gastrointestinal bleeding depend on the characteristics, severity, and acuteness of the problem. Optimal decision making requires knowledge of the P.502 probability of a serious underlying lesion and of the sensitivity and specificity of radiographic studies, endoscopy, and stool guaiac testing. Pathophysiology and Clinical Presentation (1,2,3,4,5,6,7,8,9,10) Hematemesis and Melena Hematemesis usually represents bleeding proximal to the ligament of Treitz, although the site of blood loss may on rare occasions be in the jejunum. The absence of hematemesis does not, however, exclude the possibility of active upper gastrointestinal bleeding. Melena is typically seen with blood loss proximal to the ileocecal valve, where hemoglobin is converted into hematin, which gives the stool its tarry appearance. Right -sided colonic bleeding may also cause melena when transit is slow. Representative prevalence figures from studies of outpatients and those seen in emergency departments presenting with melena or hematemesis find that about 35% have ulcer disease, 10% Mallory Weiss tears, 10% esophageal varices, 5% gastritis, and 1% gastric cancer. In 20%, no cause is found, usually because endoscopy is not performed; in 5%, multiple lesions are detected. Patients with chronic renal failure are at increased risk for bleeding, with vascular malformations and esophagitis being the mos t common causes. Hematochezia Hematochezia most often originates in the left side of the colon or anorectal region, although very brisk movement of blood from the right side of the colon, small bowel, or even stomach can lead to a similar presentation. Occult gastrointestinal bleeding may be indicated by a positive result on a test for fecal occult blood or may be suggested by the presence of iron -deficiency anemia without apparent cause. The source of occult bleeding may be anywhere in the gastrointestinal tract. In a study of anemic competitive runners, an increase in fecal hemoglobin was detected. In the setting of severe hematochezia, age has a major influence on the differential diagnosis. In young adults, Meckels diverticulum, inflammatory bowel disease, and polyps lead the list of causes. In adults to age 60 years, diverticulosis, inflammatory bowel disease, and polyps are the pred ominant etiologies, followed by malignancy and vascular malformations. In persons older

than the age of 60 years, vascular malformations, diverticulosis, malignancy, and polyps are responsible for most cases. Most patients who present with mild to moderate anorectal bleeding have lesions of the anal canal, about 15% have colorectal disease, and about 5% have perianal skin problems. Leading causes include hemorrhoids (about 50%) fissure-in-ano (20%), neoplasm (5%), and inflammatory bowel disease (5%). In close to 10% of cases, no cause is found at the time of the examination. The majority of neoplasms are more than 10 cm above the anus, beyond the reach of digital examination. In patients with undiagnosed rectal bleeding subjected to colonoscopy, almost half have significant lesions; polyps, inflammatory bowel disease, cancer, diverticular disease, and vascular malformations are the leading findings. Manifestations and Predictors of Blood Loss Clinical manifestations are a function of the rate and duration of bleeding. Postural hypotension (an orthostatic fall in blood pressure of <10 mm Hg or an increase in heart rate of >10 beats/min on moving from a supine position to standing) in the setting of known bleeding suggests intravascular volume depletion and serious acute hemorrhage. Fatigue and exertional dyspnea are typical presenting symptoms of anemia resulting from slow, chronic blood loss. Patient descriptions of the volume of bleeding are frequently unreliable. Early predictors of severity of acute lower in testinal tract bleeding include heart rate greater than 100 beats/min, systolic blood pressure less than 115 mm Hg, syncope, nontender abdominal examination, early recurrent rectal bleeding, aspirin use, and two active comorbid conditions. Gastrointestinal Bleeding in the Context of Therapeutic Oral Anticoagulation Patients with gastrointestinal bleeding while taking anticoagulant medication in the therapeutic range are likely to have an underlying lesion and warrant thorough evaluation. In a study examinin g 3,800 courses of anticoagulant therapy, gastrointestinal bleeding occurred in 45 patients. In 32 patients, a source was determined; 13 had hemorrhoids, 9 had peptic ulcers, 7 had neoplasms, and 3 had other lesions. Risk of severe upper gastrointestinal hemorrhage is significantly increased by concurrent nonsteroidal antiinflammatory drug (NSAID) use, especially in the elderly. Differential Diagnosis The chief causes of gastrointestinal bleeding can be conveniently grouped by clinical presentation (Table 63.1). Hematemesis prompts consideration of important upper gastrointestinal etiologies. Melena requires consideration of upper gastrointestinal causes and of small-intestinal and right-sided colonic sources. Hematochezia raises the question of anorectal or colonic disease and, if brisk, a small-bowel or even upper gastrointestinal lesion. The prevalence of specific disorders varies with the population studied, diagnostic methods employed, and time of investigation in relation to bleeding. Nosebleeds and respiratory tract bleeding must be considered in the differential diagnosis of melena and guaiac -positive stools. Workup (11,12,13,14,15,16,17,18,19,20) The history and physical examination may provide information regard ing the location and severity of bleeding, but additional investigations are usually

necessary to determine the exact cause. In the previously mentioned series of 311 cases of anorectal bleeding, history and physical examination alone yielded a definite diagnosis in 28%. Nevertheless, history and physical examination have important roles that help in determining the pace of workup and the selection and ordering of tests. Screening for Major Acute Blood Loss and Risk Stratification Whenever active bleeding is suspected in a person presenting to the physicians office, the first priority is to determine the P.503 severity and rate of blood loss. The patient should be asked about any postural light-headedness. The precise volume lost is not reliably determined by the history, but reports of very large amounts should be taken seriously. When the patient complains of voluminous blood loss or light -headedness, an immediate check of vital signs for postural hypotension is indicated. Immediate hospital admission should be considered if the systolic blood pressure falls more than 10 to 15 mm Hg or the heart rate increases by more than 10 to 15 beats/min when the patient stands up from a supine position. In acute lower intestinal tract bleeding, a heart rate of greater than 100 beats/min, a systolic blood pressure of less than 115 mm Hg, syncope, nontender abdominal examination, early recurrent rectal bleeding, concurrent aspirin use, or two active comorbid conditions suggest increased risk of severe bleeding. Table 63.1 Differential Diagnosis of Gastrointestinal Bleeding

Hematemesis Esophageal varices Esophagitis Esophageal ulceration MalloryWeiss tear Esophageal cancer Gastritis or duodenitis Gastric or duodenal ulcer Gastric neoplasm (carcinoma, lymphoma, or rarely leiomyoma/sarcoma) Telangiectasia Angiodysplasia, especially in patients with renal failure Melena All causes of hematemesis plus: Meckels diverticulum Crohns disease Small-bowel neoplasms (rare) Hematochezia Hemorrhoid Anal fissure

Colonic polyp Colorectal carcinoma Angiodysplasia Diverticular disease Inflammatory bowel disease Any upper gastrointestinal or small-bowel lesion if bleeding is brisk

Risk stratification helps to determine the need for admission and early endoscopic evaluation and treatment. Clinical predictors of poor prognosis include age older than 65 years, comorbid illness or poor overall health status, fresh blood on rectal examination or in the emesis, hypot ension, and continued bleeding. A low hemoglobin level is also predictive of increased risk, but decline in hemoglobin or hematocrit in the acute phase of blood loss may be deceptively small if sufficient time for reequilibration of intravascular volume has not elapsed. History Once it is clear that the speed or volume of blood loss does not pose an immediate hazard, the office evaluation can proceed. Clarifying the nature of the bleeding (melena, hematemesis, or hematochezia) helps not only to assess severity, but also to identify the approximate site of bleeding. Obtaining an accurate description is essential, as is checking for potentially confounding factors. Dark stools must not be mistaken for genuine melena, and one should check for intake of substances that may turn stool black, such as bismuth (Pepto-Bismol), iron, charcoal, or spinach. Red stools can occur after large quantities of beets have been eaten. Factors that can produce a false -positive result on the stool Hemoccult test should be considere d (e.g., use of cough syrup containing glycerol guaiacolate, a recent meal of rare red meat), but a positive test result should not be dismissed lightly. When hematemesis is reported, sources of esophageal, gastric, and duodenal bleeding must be sought. A history of cirrhosis, chronic liver disease, or alcoholism raises suspicion of esophageal varices. Use of aspirin, alcohol, or NSAIDs suggests bleeding caused by ulceration or gastritis. A history of peptic ulcer or the presence of epigastric pain responsi ve to antacids or related to food intake raises the possibility of bleeding from a gastric or duodenal ulcer, as does knownHelicobacter pylori infection, especially in the setting of NSAID use. Another explanation for bleeding needs to be kept in mind in p atients with a history typical of ulcer disease; more than one potential site of bleeding may be discovered (e.g., esophageal varices). Even if no hematemesis is noted, the source may still be above the ligament of Treitz; however, small -bowel and

colonic lesions become more likely. Diarrhea, urgency, tenesmus, and lower abdominal cramping suggest inflammatory bowel disease (see Chapter 73). With ulcerative colitis, diverticulosis, and other forms of rectosigmoid disease, some frank rectal bleeding is often present. Brisk rectal bleeding in the absence of abdominal pain is particularly common with diverticular disease. Weight loss or change in bowel habits raises suspicion of colonic cancer. A history of diverticular disease may be a clue to the cause of blood loss, but a coincident carcinoma must be ruled out. Many patients with rectal bleeding admit to past or present hemorrhoidal problems, but in almost half of the cases, another lesion is found to be the cause of blood loss. Physical Examination As noted previously, when evidence of acute bleeding is present, the evaluation should begin with a check for postural signs and a cardiopulmonary examination to assess the severity of volume loss and the presence of any hemodynamic compromise. Next, the skin is inspected for pallor, ecchymoses, petechiae, telangiectases, and stigmata of chronic liver disease (e.g., jaundice, palmar erythema, spider angiomata). The nose and pharynx are examined for sources of bleeding. Lymph nodes are palpated for enlargement (e.g., left supraclavicular adenopathy suggests an intraabdominal malignancy), and the abdomen is palpated for organomegaly, ascites, and masses. Anorectal lesions are sought on inspection and digital examination; the stool is checked for color and the presence of occult blood (see Chapter 56). Anoscopy is an essential part of the examination for patients who complain of anal symptoms. If the patient convincingly describes hematemesis, one may assume that the bleeding is from the upper gastrointestinal tract, but if th ere is evidence of recent significant bleeding of uncertain origin, a nasogastric tube should be passed to aspirate gastric contents and examined for the presence of blood. P.504

Laboratory Studies Laboratory studies should be performed to determine the chronicity and magnitude of blood loss and the presence of coincident disease. The hemoglobin concentration should be measured in all patients; however, if blood loss is acute, the hemoglobin concentration may not yet accurately reflect the severity of blood loss. A low mean corpuscular volume suggests the possibility of iron deficiency resulting from chronic gastrointestinal blood loss. Studies of coagulation (platelet count, prothrombin time, and partial thromboplastin time) and tests of liver and renal function are useful in checking for factors that may exacerbate bleeding. Hematochezia In stable patients, the main concern is the possibility of colon cancer; risk increases with age. Fewer than 5% of such cancers occur in patients younger than age 40 years, and fewer than 1% in those younger than age 30 years. Thus, if the physical examination or anoscopy reveals a bleeding hemorrhoid or other cause of local anal pathology in a young patient, it may not be necessary to proceed with further tests. The finding on sigmoidoscopy of stool negative for

occult blood from above the point of bleeding also provides reassurance. On the other hand, 80% of colorectal malignancies are found in patients older than the age of 50 years. When a person older than 50 years old presents with rectal bleeding, a thorough search for tumor is required, even if a local lesion such as a hemorrhoid is discovered. Twenty-seven percent of patients with carcinoma of the rectum and 10% of those with carcinoma of the sigmoid have been noted to have coincidental hemorrhoids. Colonoscopy is the diagnostic procedure of choice for patients with hematochezia who are at risk for colon cancer and whose bleeding is not entirely explained by documented anorectal pathology. Most patients older than the age of 40 years with rectal bleeding are candidates for colonoscopy, which is indicated for all patients whose bleeding is not clearly anorectal and whose source is beyond the range of the sigmoidoscope. There is increasing interest in computed colonography, but data are insufficient to establish its role in the assessment. Hematemesis Endoscopy has proved diagnostically superior to barium studies and offers the possibility of tissue biopsy for H. pylori. The sensitivity of the upper gastrointestinal series is around 60%, compared with 95% for endoscopy. Esophagitis, MalloryWeiss tears, and gastritis, which are often undetectable radiologically, are readily seen by endoscopy. Moreover, barium obscures mucosal detail and interferes with endoscopy for 24 to 48 hours. Thus, for suspected acute brisk upper gastrointestinal bleeding, endoscopy is the procedure of first choice, with barium study reserved as a supplementary procedure for patients with inactive bleeding, unexplained chronic blood loss, or suspected small-bowel disease. Early endoscopy (within the first 24 hours) is indicated in persons who manifest hemodynamic signs of severe bleeding or are deemed to be at high risk. In most hemodynamically stable patients, early endoscopy probably does not resu lt in improved outcome for patients with hematemesis, but it does provide a clear diagnosis and helps to predict the risk for further bleeding. Patients with small bleeds who are hemodynamically stable and do not have liver disease or a significant risk for gastric cancer may be presumed to have peptic ulcer disease and can be treated for Helicobacter- or NSAID-induced peptic ulcer (see Chapter 68). Patients at high risk for recurrent bleeding (such as those with evidence of chronic liver disease or an initial bleed that requires a transfusion) and those with persistent bleeding despite medical therapy should undergo early endoscopy. In addition, it may be useful to perform upper gastrointestinal endoscopy to exclude esophageal and gastric mucosal features indicative of a high risk for rebleeding (e.g., a visible vessel in an ulcer crater). Melena Because melena may have an upper or lower gastrointestinal source, one needs to decide which part of the gastrointestinal tract to evaluate first. The decision must be individualized to the patient, although, in general, an upper gastrointestinal source of bleeding is more likely. Occult Bleeding

The evaluation of occult gastrointestinal bleeding is generally aimed at detecting asymptomatic neoplasms at a curable stage. Because colonic adenomas and carcinomas are the most common gastrointestinal neoplasms, evaluation of the colon has greatest utility in this setting. A cost -effectiveness analysis comparing different strategies for evaluating a positive result on testing for fecal occult blood suggested that colonoscopy would save more lives at lower cost than the combined use of barium enema and flexible sigmoidoscopy. The orally passed video capsule is emerging as a valuable tool for the evaluation of occult bleeding, especially of the small bowel. If no cause of occult bleeding is identified within the colon, evaluation of the upper gastrointestinal tract and small bowel may be considered, although the yield for detection of cancer is likely to be low. In a study of 26 patients followed for 2 to 8 years after a negative result on colonoscopy or barium enema/sigmoidoscopy, only 1 patient was later found to have a gastric cancer. In 5 others, a nonmalignant upper gastrointestinal source emerged as the cause of the occult bleeding. A prospective study of patients with iron -deficiency anemia found that site-specific symptoms predicted the location of the source of bleeding. Upper gastrointestinal sources were common. Synchronous sources of blood loss were rare, so further evaluation was unnecessary when an obvious source was found. Prophylactic and Symptomatic Management (21,22,23,24,25,26,27,28,29) Patients at high risk for upper gastrointestinal bleeding (such as those with varices or a prior history of upper gastrointestinal bleeding, especially if exposed to anticoagulants, NSAIDs, or H. pylori infection) are candidates for prophylactic measures (see Chapters 68 and 71). For patients with varices, beta blockade has been used successfully to prevent a first bleed in patients with known varices (see Chapter 71). Endoscopic ligationmay also be used for primary prophylaxis in patients with varices but is less cost-effective than other measures; the procedure may also be considered for secondary prophylaxis. For patients with a history of bleeding from an ulcer or gastritis, histamine 2 blockers and proton-pump inhibitors (PPIs) P.505 are worth consideration in selected patients, especially those requiring chronic NSAID or aspirin therapy. Controlled trial finds that patients on aspirin therapy for cardiovascular prophylaxis who had a gastrointestinal bleed have less recurrent bleeding by adding the PPI esomeprazole to their aspirin program than by switching to clopidogrel. Any concurrent Helicobacter infection should be identified and fully treated (see Chapter 68). The prostaglandin analogue misoprostol might be an adjunct to acid suppression for patients who continue to require NSAID therapy. Patients taking steroids do not appear to require such prophylaxis unless an additional risk factor for bleeding is present. Modest falls in hematocrit that accompany chronic low -grade gastrointestinal blood loss can be treated with oral iron (300 mg of ferrous sulfate three times daily) to make up for the resulting iron deficiency (see Chapter 82). Marked but gradual decreases in hematocrit are usually well tolerated unless the patient

has cardiopulmonary disease. Most patients do not need transfusion unless they are symptomatic. Oral iron usually produces a prompt ret iculocytosis and at least partial correction of the anemia (see Chapter 82). Patients with presumed anal bleeding can be given fiber supplements or stool softeners to decrease mechanical trauma to the lesion (see Chapter 65). Indications for Admission and Referral The patient with a story of recent or ongoing brisk bleeding, especially if it is accompanied by orthostatic hypotension or other symptoms or signs of hemodynamic compromise, requires emergency department evaluation. Prompt hospitalization is indicated for the person with a profound anemia, even in the absence of evidence for dramatic blood loss. Some patients who are hemodynamically stable may be expeditiously evaluated in a short stay with endoscopy. Hospitalization should be considered for patie nts with a lower tract source disease or less severe or perhaps even chronic gastrointestinal blood loss if they have a concurrent condition that might be aggravated by anemia (e.g., ischemic heart disease). For most others, evaluation can proceed safely o n an ambulatory basis if the patient does not have serious cardiopulmonary disease and is responsible enough to recognize and promptly report signs of worsening blood loss or volume depletion. Referral to a gastroenterologist should be considered for patients who are potential candidates for endoscopy and also for patients whose source of bleeding remains elusive after initial evaluation. Annotated Bibliography 1. Battistella M, Mamdami MM, Juurlink DN, et al. Risk of upper gastrointestinal hemorrhage in warfarin users treated with nonselective NSAIDS or COX -2 inhibitors. Arch Intern Med 2005;165:189. ( Casecontrol study; the risk nearly doubles and is similar for both classes of nonsteroidal antiinflammatory drugs [NSAIDs].) 2. Carson JL, Strom BL, Schinnar R, et al. The low risk of upper gastrointestinal bleeding in patients dispensed corticosteroids. Am J Med 1991;91:223. ( The risk was 2.8 cases per 10,000 person-months, arguing against prophylactic therapy unless other risk factors are present .) 3. Graham DY. Aspirin and the stomach. Ann Intern Med 1986;104:390. (Comprehensive review noting that the degree of mucosal injury seen by endoscopy does not predict the risk for or the degree of bleeding .) 4. Papatheodoridis GV, Papdelli D, Cholongitas E, et al. E ffect of Helicobacter pylori infection of the risk of upper gastrointestinal bleeding in users of nonsteroidal anti-inflammatory drugs. Am J Med 2004;116:601. ( The risk is doubled by the presence of the infection. ) 5. Sharara AI, Rockey DC. Gastroesophagea l variceal hemorrhage. N Engl J Med 2001;345:669. (Detailed review; 118 references.) 6. Stewart JG, Ahlquist DA, McGill DB, et al. Gastrointestinal blood loss and anemia in runners. Ann Intern Med 1984;100:843. ( Documents an increase in fecal hemoglobin.) 7. Wilcox CM, Alexander LN, Cotsonis G. A prospective characterization of upper gastrointestinal bleeding with hematochezia. Am J Gastroenterol 1997;92:231.

(Duodenal ulcer is a common cause of upper tract bleeding presenting as hematochezia.) 8. Wilcox CM, Truss CD. Gastrointestinal bleeding in patients receiving long term anticoagulant therapy. Am J Med 1988;84:683. ( Half of episodes were upper gastrointestinal in origin; a lower gastrointestinal origin was noted in 33%.) 9. Yuan Y, Tsoi K, Hunt RH. Selective serotonin reuptake inhibitors and risk of upper GI bleeding: confusion or confounding? Am J Med 2006:119:719. ( A systematic review finding that the evidence was weak for the association but was strongest in those taking NSAIDs or aspirin concurrently ). 10. Zuckerman GR. Upper gastrointestinal bleeding in patients with chronic renal failure. Ann Intern Med 1985;102:588. ( Upper gastrointestinal angiodysplasia was the most common source; esophagitis was also prevalent .) 11. Barkun A, Bardou M, Marshall JK, et al. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2003;139:843. (Sections on risk stratification and the need for early endoscopy are especially useful for the primary physician .) 12. Barry MJ, Mulley AG, Richter JM. Effect of workup strategy on the cost effectiveness of fecal occult blood screening for colorectal cancer. Gastroenterology 1987;93:301. (Comparative analysis of seven potential strategies for evaluating the colon in as ymptomatic patients with guaiacpositive stool.) 13. Cave DR. Obscure gastrointestinal bleeding: the role of the tagged red blood cell scan, enteroscopy, and capsule endoscopy. Clin Gastroenterol Hepatol 2005;10:959. (A current review of new techniques to examine the small bowel and investigate obscure bleeding sources. ) 14. Farrell JJ, Friedman LS. Review article: the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther 2005;21:1281. ( An updated review of the approach to lower intestinal bleeding.) 15. Griffiths WJ, Neumann DA, Welsh JD. The visible vessel as an indicator of uncontrolled or recurrent gastrointestinal hemorrhage. N Engl J Med 1979;300:1411. (Classic paper; identifies an important sign of high risk for repeat hemorrhage.) 16. Harewood GC, McConnell JP, Harrington JJ, et al. Detection of occult upper gastrointestinal bleeding: performance differences in fecal occult blood tests. Mayo Clin Proc 2002;77:23. (Cross-sectional study with useful data.) 17. Jensen DM, Machicado GA, Jutabha R, et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000;342:78. (Prospective cohort study; early scoping and treatment improved outcomes.) 18. Rockey DC. Occult gastrointestinal bleeding. N E ngl J Med 1999;341:38. (A comprehensive review of testing for occult bleeding .) 19. Rockey DC, Cello JP. Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia. N Engl J Med 1993;329:1691. ( Lesions are frequently found; site-specific symptoms help to predict location and direct workup .)

20. Simon JB. Fecal occult blood testing: clinical value and limitations. Gastroenterologist 1998;6:66. (Detailed review of the test, with a good discussion of its limitations.) 21. Barkin JS, Ross BS. Medical therapy of chronic gastrointestinal bleeding of obscure origin. Am J Gastroenterol 1998;93:1250. ( Patients who had chronic occult bleeding, often elderly persons with suspected vascular ectasia, improved with combination estrogen and progestero ne therapy.) 22. Chan FKL, Chung SCS, Suen BY, et al. Preventing recurrent upper gastrointestinal bleeding in patients with Helicobacter pylori infection who are taking low-dose aspirin or naproxen. N Engl J Med 2001;344:967. ( Randomized trial; eradication of infection and use of omeprazole were found to be helpful when NSAIDs were resumed.) 23. Chan KLC, Ching SYL, Hung LCT, et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med 2005;352:238. (A randomized, controlled trial; aspirin plus proton pump inhibitor therapy was superior to clopidogrel in the prevention of recurrent ulcer bleeding. ) 24. Laine L, El Newihi HM, Migikovsky B, et al. Endoscopic ligation compared with sclerotherapy for the treatment of bleed ing esophageal varices. Ann Intern Med 1993;119:1. (Endoscopic ligation caused fewer local complications and eradicated varices more rapidly .) 25. Lau JYW, Sung JJY, Lam YH, et al. Endoscopic retreatment compared with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 1999;340:751. (Endoscopic retreatment is more cost -effective than emergency surgery.) P.506

26. Longstreth GF, Feitelberg SP. Outpatient care of selected patients with acute non-variceal upper gastrointestinal haemorrhage. Lancet 345;1995:108. (A substantial proportion of selected patients with nonvariceal bleeding can be safely treated without hospital admission. ) 27. Rokkas T, Karameris A, Mavrogeorgis A, et al. Eradication of Helicobacter pylori reduces the possibility of rebleeding in peptic ulcer disease. Gastrointest Endosc 1995;41:1. (Patients with duodenal ulcer disease had fewer episodes of bleeding if they were successfully treated for Helicobacter pylori .) 28. Strate LL, Orav EJ, Syngal S. Early predictors of severity in acute lower intestinal tract bleeding. Arch Intern Med 2003;163:838. ( A prospective cohort study; identified tachycardia, hypotension, syncope, nontender abdomen, and recurrent bleeding per rectum as independent predict ors.) 29. Sung JJY, Chan FKL, Lau JYW, et al. The effect of endoscopic therapy in patients receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots: a randomized comparison. Ann Intern Med 2003;139:237. (Adding endoscopic therapy was better than using omeprazole alone.) http://www.dermaamin.com/site/images/stories/fruit/Primarycaremedicine/sid436397.ht ml