Upper gastrointestinal bleeding (UGIB) is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and rarer causes such as gastric cancer. The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine the hemoglobin. Significant upper gastrointestinal bleeding is considered a medical emergency. Fluid replacement, as well as blood transfusion, may be required. Endoscopy is recommended within 24 hours and bleeding can be stopped by various techniques. Proton pump inhibitors are often used. Tranexamic acid may also be useful. Procedures (such as TIPS for variceal bleeding) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment. Upper gastrointestinal bleeding affects around 50 to 150 people per 100,000 a year. It represents over 50% of cases of gastrointestinal bleeding. A 1995 UK study found an estimated mortality risk of 11% in those admitted to hospital for gastrointestinal bleeding.
Signs and symptoms Persons with upper gastrointestinal bleeding often present with hematemesis, coffee ground vomiting, melena, or hematochezia (maroon-coloured stool) if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage. A person with upper gastrointestinal bleeding may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath. The physical examination performed by the physician concentrates on the following things:
Vital signs, in order to determine the severity of bleeding and the timing of intervention Abdominal and rectal examination, in order to determine possible causes of hemorrhage Assessment for portal hypertension and stigmata of chronic liver disease in order to determine if the bleeding is from a variceal source. Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.
Causes
A number of medications increase the risk of bleeding including NSAIDs and SSRIs. SSRIs double the rate of upper gastrointestinal bleeding. There are many causes for upper gastrointestinal hemorrhage. Causes are usually anatomically divided into their location in the upper gastrointestinal tract. People are usually stratified into having either variceal or non-variceal sources of upper gastrointestinal hemorrhage, as the two have different treatment algorithms and prognosis. The causes for upper gastrointestinal hemorrhage include the following:
Esophageal causes (gastrorrhagia): Esophageal varices Esophagitis Esophageal cancer Esophageal ulcers Mallory-Weiss tear Gastric causes: Gastric ulcer Gastric cancer Gastritis Gastric varices Gastric antral vascular ectasia Dieulafoy's lesions Duodenal causes: Duodenal ulcer Vascular malformation, including aorto-enteric fistulae. Fistulae are usually secondary to prior vascular surgery and usually occur at the proximal anastomosis at the third or fourth portion of the duodenum where it is retroperitoneal and near the aorta. Hematobilia, or bleeding from the biliary tree Hemosuccus pancreaticus, or bleeding from the pancreatic duct Severe superior mesenteric artery syndrome
Diagnosis
Diagnostic testing The strongest predictors of an upper gastrointestinal bleed are black stool, age <50 years, and blood urea nitrogen/creatinine ratio 30 or more. The diagnosis of upper gastrointestinal bleeding is assumed when hematemesis (vomiting of blood) is observed. A nasogastric aspirate can help determine the location (source) of bleeding and help understand the best initial diagnostic and treatment plan. Nasogastric aspirate has a sensitivity of 42%, specificity 91%, negative predictive value 64%, positive predictive value 92% and overall accuracy of 66% in differentiating upper gastrointestinal bleeding from bleeding distal to the ligament of Treitz. A positive aspirate is more helpful than a negative aspirate (If the aspirate is positive, an upper gastrointestinal bleed is likely; if the aspirate is negative, the source of a gastrointestinal bleed is probably, but not certainly, lower). A smaller study found a sensitivity of 79% and specificity of 55%, somewhat opposite results from Witting. The accuracy of the aspirate is improved by using the Gastroccult test. Determining whether blood is in gastric contents, either vomited or aspirated specimens, may be a challenge when determining the source of the hemorrhage. Slide tests are based on orthotolidine (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). There is some evidence that orthotolidine-based tests more sensitive than specific, the Hemoccult test's sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate.
Bayesian calculation The predictive values cited are based on the prevalences of upper gastrointestinal bleeding in the corresponding studies. A clinical calculator can be used to generate predictive values for other prevalences.
Treatment The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood. A number of medications may improve outcomes depending on the source of the bleeding. Proton pump inhibitor medications are often given in the emergent setting before an endoscopy and may reduce the need for an endoscopic haemotstatic treatment. Proton pump inhibitors decrease gastric acid production. There is insufficient evidence to determine if proton pump inhibitors decrease death rates, re-bleeding events, or the need for surgical interventions. After the initial resuscitation has been completed, treatment is instigated to limit the likelihood of re-bleeds and correct any anemia that the bleeding may have caused. Those with a Glasgow Blatchford score less than 2 may not require admission to hospital.
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