Introduction

Here, we deal primarily with massive losses of blood from the digestive tract and their causes. However, since small hemorrhages often enlarge spontaneously, it is implicit that urgent attention must be paid to indications of even slight bleeding episodes, i.e. those manifested by positive testing of stools for occult blood or a single melenic stool.

A truly melenic stool is usually shiny black and almost invariably represents bleeding from above the ileocecal valve. A dull black stool is often not true melena and is negative to occult blood testing. Such stool coloring is usually the result of ingested medications or foods, particularly iron-containing supplements or bismuth, or dark-green leafy vegetables like spinach. The greater the rate of bleeding, the looser and redder the stool becomes. The higher the level of bleeding in the digestive tract, the greater is the fetid odor of the feces. This is probably a result of partial digestion of blood proteins in the upper intestine. Grossly bloody stools, or actual blood clots, can come from any level of the bowel, with the more malodorous and the more darkly red coming from higher levels. Significant gastrointestinal bleeding from above the cecum is usually accompanied by elevation of the blood urea nitrogen (BUN) level. This is due to the large protein bolus in the lumen of the small intestine and the reduced renal circulation resulting from compromise of blood volume.

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