Bleeding Ulcers: Symptoms and Causes

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Medical Author: Benjamin C. Wedro, MD, FAAEM
Medical Editor: Melissa Conrad Stöppler, MD

It started with feeling a little run down after working extra hard, perhaps there was some lightheadedness when he stood too quickly, and then came the fatigue. The baseball world blamed Ichiro Suzuki's malaise on playing too much in the World Baseball Classic. This time of year, baseball players are supposed to lounge in spring training and gradually get themselves into shape, not play like it's the World Series in October. But the baseball world was wrong. It was discovered in April 2009 that Ichiro was tired because he was anemic and because he was bleeding from an ulcer.

The scenario plays out routinely off the playing field too often. A person feels run down and blames it on all sorts of circumstances, but finally presents to their doctor to get some help. The clues come from the history of heartburn and indigestion, or maybe it was the extra aspirin or ibuprofen to help with the stress headaches at work. There may be a little tenderness in the belly, and after some coercion on the part of the doctor, the patient agrees to a rectal exam. It shows that the stool has occult blood in it; that is blood that cannot be seen with the naked eye but shows up with a chemical test. A blood test (CBC) shows that the patient is anemic, meaning there is a low red blood cell count. Put the clues together and the doctor tells the patient that the fatigue and tiredness is due to bleeding.

The stomach is a mixing bowl, allowing food and digestive juices to combine and allow digestion to begin. But the stomach has a protective lining that prevents digestive enzymes from eating away at it. If this lining is damaged, inflammation and pain may occur. If the inflammation becomes worse, it can cause the lining of the stomach or the duodenum (the first part of the small intestine) to bleed. The bleeding may not be noticeable, and the patient may not seek medical care.

Red blood cells carry oxygen to all the organs of the body. If there are too few red cells, symptoms may occur. Some of these symptoms are pretty non-specific, like fatigue, weakness, or lack of energy. As the anemia becomes more severe, shortness of breath or chest discomfort during activity may occur. Lightheadedness may occur if a person stands too quickly, since the body isn't able to pump oxygen-carrying red blood cells fast enough to the brain. It usually resolves in a few seconds as the body adapts or if the person sits down. Sometimes, though, the lightheadedness leads to "passing out."

Inflammation in the stomach may also cause a small crater, or ulcer, to form. If there happens to be a blood vessel under the ulcer, a lot of bleeding can develop and then the symptoms aren't so subtle. The patient may vomit blood, or the blood may pass into the intestine, get digested, and come out as black, tarry stools.