Upper gastrointestinal hemorrhage (UGIH) describes bleeding arising from a site proximal to the ligament of Treitz [1] [2]. The leading etiology of UGIH is peptic ulcer disease (PUD), which accounts for 60% of cases and is significantly associated with Helicobacter pylori infection [3] [4]. Other potential causes are Mallory-Weiss tear, gastritis, duodenitis, arteriovenous malformations, esophageal varices, and malignancy [2] [3]. Important risk factors are a history of nonsteroidal anti-inflammatory drug (NSAID) use, alcohol abuse, and chronic renal failure [5]. Other risk factors include chronic liver disease, portal hypertension, and use of certain medications.

UGIH is more predominant in men and in advanced ages [3]. Patients typically report signs such as melena, hematochezia, hematemesis, epigastric or generalized abdominal pain, presyncope, and heartburn [6]. In acute hemorrhage, hematemesis and melena are frequent complaints. Other possible manifestations are chest pain, dysphagia, weight loss, jaundice, and syncope [2] [6].

UGIH is associated with significant morbidity and mortality. Moreover, the risk of death is correlated with factors such as older age and the presence of comorbidities [7] [8]. Another complication is rebleeding, which occurs in 15% of patients [9].

• Anemia

  Three and six months after the bleeding episodes, neither the HRQoL nor fatigue was affected by the anemia. CONCLUSION: This study did not uncover relationships between anemia and HRQoL or anemia and fatigue after nonvariceal AUGIB. [ncbi.nlm.nih.gov]

• Fever

  Abstract Gastrointestinal (GI) hemorrhage is not a common complication of Mediterranean spotted fever (MSF). [ncbi.nlm.nih.gov]

  […] dizziness Physical exam positive stool guiaic hypotension tachycardia fever Evaluation CBC recall that hematocrit is not an accurate measure of blood loss may be used to monitor treatment (i.e. effectiveness of transfusions) NG tube / NG lavage may be [medbullets.com]

  A 64-year-old man with a history of coronary artery disease and peripheral vascular disease was admitted with a several-month history of fevers, chills, and fatigue. [content.nejm.org]

  Baseline chest radiographs were performed and sputum specimens were collected from all patients, and those patients without clear signs of pneumonia (positive chest radiograph, positive cough, fever) at baseline were followed prospectively for the development [dukespace.lib.duke.edu]

• Chills

  A 64-year-old man with a history of coronary artery disease and peripheral vascular disease was admitted with a several-month history of fevers, chills, and fatigue. [content.nejm.org]

  These include: The area around your wound is more red or painful Your wound area is very warm to touch You have a fever higher than 101.5° F (38.6° C) You have blood, pus, or other fluid coming from the wound area You have chills or muscle aches Developed [summitmedicalgroup.com]

  "A Stitch in Time — A 64-year-old man with a history of coronary artery disease and peripheral vascular disease was admitted to the hospital with a several-month history of fevers, chills, and fatigue". [en.wikipedia.org]

• Pallor

  General examination focuses on vital signs and other indicators of shock or hypovolemia (eg, tachycardia, tachypnea, pallor, diaphoresis, oliguria, confusion) and anemia (eg, pallor, diaphoresis). [merckmanuals.com]

  In more severe cases of chronic or acute bleeding, symptoms may include signs of anemia, such as weakness, pallor, dizziness, shortness of breath or angina. [wakegastro.com]

  Classification of haemorrhagic shock 1 Examination Inspect: Pallor suggests significant anaemia Jugular venous pressure: reduced in hypovolaemia, but often difficult to assess clinically Feel: Assess peripheries – these will often be cool in patients [geekymedics.com]

  A secondary aim is to look for signs of underlying disease and significant comorbid conditions - for example: Pallor and signs of anaemia should be sought. Pulse and blood pressure. [patient.co.uk]

• Acutely Ill Patient

  Primary prophylaxis for acutely ill patients in critical care: [ 2 ] Acid-suppression therapy (H 2 -receptor antagonists or PPIs) should be offered for primary prevention of UGIB in acutely ill patients admitted to critical care (using the oral form of [patient.co.uk]

• Melena

  Patients typically report signs such as melena, hematochezia, hematemesis, epigastric or generalized abdominal pain, presyncope, and heartburn. In acute hemorrhage, hematemesis and melena are frequent complaints. [symptoma.com]

  Reported cases of gastrointestinal hemorrhage have been in the form of coffee ground emesis, melena, or hematochezia. Such bleeding complications have resulted from ischemic ulceration or perforation of the small or large intestine. [arizona.pure.elsevier.com]

  An 11-year-old child with a history of hepatic trauma 6 months before was admitted for hematemesis and melena. Repeat ultrasound examination showed a 3.6 × 2.8 cm anechoic area with clear border in the right hepatic lobe. [ncbi.nlm.nih.gov]

• Hematemesis

  Patients typically report signs such as melena, hematochezia, hematemesis, epigastric or generalized abdominal pain, presyncope, and heartburn. In acute hemorrhage, hematemesis and melena are frequent complaints. [symptoma.com]

  This retrospective cohort study involved patients admitted via the ED for GI tract bleeding without hematemesis, who underwent confirmatory testing. [ncbi.nlm.nih.gov]

  However, we are unaware of previous reports showing massive hematemesis to be the initial presentation of PAN. [arizona.pure.elsevier.com]

• Vomiting

  Clinical features of upper gastrointestinal bleeding Symptoms Abdominal pain – may be epigastric or diffuse Haematemesis – vomiting of bright red blood Coffee-ground vomit – vomiting of black material (blood altered by gastric acid) Melaena – black tarry [geekymedics.com]

  The colour of the vomited blood is dependent on the concentration of HCL and its admixture with the blood .If the vomiting occurs soon after the UGIB, then haematemesis will be bright red in colour. [howmed.net]

  Abstract Mallory-Weiss tears are a common cause of upper gastrointestinal bleeding and are often associated with vomiting from heavy alcohol ingestion. [ncbi.nlm.nih.gov]

• Gastropathy

  Other less common causes were erosive gastritis (1.8%), Mallory Weiss tear (1.8%), and retch gastropathy (1.1%). Non steroidal anti inflammatory (NSAID) ingestion was reported in 7.56% of cases. Melena was the commonest mode of presentation. [ncbi.nlm.nih.gov]

  MalloryWeiss medications metaanalysis modalities mucosal nonvariceal upper gastrointestinal NVUGIB ofthe outcomes patients with cirrhosis patientswith peptic ulcer peptic ulcer bleeding pepticulcer pharmacologic portal hypertension portal hypertensive gastropathy [books.google.de]

  […] oesophageal and gastric varices gastritis oesophagitis duodenitis Mallory-Weiss tear angiodysplasia upper GI malignancy anastamotic ulcers Dieulafoy lesion (congenital submucosal artery) Other important causes aortoenteric fistula portal hypertensive gastropathy [aic.cuhk.edu.hk]

  […] differences in the approach to management CAUSES Upper GI Bleeding peptic ulcer disease (75% are gastric, rather than duodenal) Varices (90% are oesophageal, rather than gastric) Oesophagitis Gastritis Duodenitis Mallory-Weiss tears Portal hypertensive gastropathy [lifeinthefastlane.com]

  Isabelle Colle, Xavier Verhelst, Anja Geerts and Hans Van Vlierberghe, Varices, portal hypertensive gastropathy and GAVE, Cirrhosis: A practical guide to management, (137-150), (2015). Dominik F. Draxler and Robert L. [doi.org]

• Black Stools

  Black stool, age less than 50 years, and blood urea nitrogen/creatinine ratio of 30 or greater independently predict an upper GI tract bleeding source. [ncbi.nlm.nih.gov]

  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. [en.wikipedia.org]

  In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more. [ipfs.io]

  Examples of colors of stools and the causes include: Black, tarry, sticky stools: Gastritis (bleeding from the stomach) Black stools (no odor, not sticky): Medications like iron pills or bismuth-containing medications (Pepto-Bismol) Yellow stools: Celiac [emedicinehealth.com]

  A black, tarry stool (melena) often indicates an upper GI source of bleeding although it could originate from the small intestine or right colon. Other causes of a black stool might include iron or ingestion of bismuth (Pepto-Bismol). [wakegastro.com]

• Hypotension

  Worrisome signs are tachycardia, hypotension (systolic blood pressure < 90 mm Hg), orthostatic hypotension, and findings indicative of poor perfusion such as cool extremities. [symptoma.com]

  […] malaise/weakness fever dizziness Physical exam positive stool guiaic hypotension tachycardia fever Evaluation CBC recall that hematocrit is not an accurate measure of blood loss may be used to monitor treatment (i.e. effectiveness of transfusions) NG [medbullets.com]

  Rembacken Dealing with upper gastrointestinal (UGI) bleeding is fraught with pitfalls, not least because spotting those patients who are suffering significant bleeding can be difficult amongst the majority of referrals who are ill and hypotensive for [ueg.eu]

  Absolute hypotension Disability Confusion Reduced conscious level Exposure Abdominal examination Guarding/rigidity Masses Per rectum (PR) examination to look for melaena or haematochezia Signs of chronic liver disease Jaundice, ascites Hands: clubbing [oxfordmedicaleducation.com]

In patients with suspected UGIH, rapid triage will allow the clinician to promptly identify and subsequently resuscitate hemodynamically unstable patients [2]. Furthermore, the clinician should elicit the patient's personal history, the list of medications, and risk factors.

Physical exam

Vital signs are used to assess whether the patient is hemodynamically stable or not. Worrisome signs are tachycardia, hypotension (systolic blood pressure < 90 mm Hg), orthostatic hypotension, and findings indicative of poor perfusion such as cool extremities.

Remarkable abdominal exam findings may contain rebound tenderness, guarding, and evidence of chronic liver disease, while a rectal exam may reveal the presence of blood [2].

Laboratory tests

A complete blood count (CBC), which is key to gauge the blood loss, should be obtained every 4 to 6 hours in order to track and follow the trends. Other important tests are incorporated in a complete metabolic panel (CMP), which evaluates renal and liver function, electrolyte levels, and other parameters, while a coagulation profile is obtained to assess possible coagulopathy. Moreover, a type and cross match is required in case a transfusion is warranted [2].

Diagnostic tests

Stabilized patients will undergo upper endoscopy, which is the recommended initial diagnostic study for UGIH [10]. This procedure also allows for endoscopic treatment as well [2]. There may be a role for the use of capsule endoscopy (CE) to identify patients with low-risk lesions [11].

Nasogastric lavage is utilized to help confirm bleeding and allows for visualization and characterization of the contents.

To evaluate for pathologies such as cirrhosis, pancreatitis, and other rare causes of UGIH, imaging modalities such as computed tomography (CT) scan and ultrasonography are useful [12]. Additionally, chest radiography is used to exclude aspiration pneumonia, esophageal perforation, and other manifestations.

In patients with a negative endoscopy and those with bleeding that is refractory to endoscopic treatment, angiography with transcatheter arterial embolization (TAE) should be considered [10].

Other

An electrocardiogram (EKG) is used to rule out acute myocardial infarction, arrhythmias, and other cardiac-related consequences.

• Mediastinal Mass

  Lateral skiagram of the chest showed a posterior mediastinal mass. CT scan of the chest revealed a ruptured aortic aneurysm into the oesophagus, confirmed the diagnosis. [ncbi.nlm.nih.gov]

• Posterior Mediastinal Mass

  Lateral skiagram of the chest showed a posterior mediastinal mass. CT scan of the chest revealed a ruptured aortic aneurysm into the oesophagus, confirmed the diagnosis. [ncbi.nlm.nih.gov]

histamine-2 receptor antagonist (H2RA) or no treatment prior to endoscopy. [ncbi.nlm.nih.gov]

Of these, 1114 were randomised to PPI treatment and 1109 to control treatment. [doi.org]

Treatment after first or failed endoscopic treatment [ 2 ] Repeat endoscopy, with treatment as appropriate, should be considered for all patients at high risk of re-bleeding, particularly if there is doubt about adequate haemostasis at the first endoscopy [patient.co.uk]

Shock: the presence of signs of shock at presentation confers a worse prognosis. [patient.co.uk]

In contrast to the acute leukemias, chronic lymphocytic leukemia (CLL) is a hematological malignancy with a generally good prognosis. [ncbi.nlm.nih.gov]

Almost nothing has been reported on longer term prognosis following upper GI bleeding. [journals.plos.org]

The figures from our study are true reflection of the real etiological spectrum of UGIB in this region. [ncbi.nlm.nih.gov]

From the Departments of Therapeutics and Epidemiology & Community Medicine University Hospital Nottingham UK [link.springer.com]

There is sparse knowledge of recent epidemiology and outcomes. We wanted to evaluate the characteristics and outcomes of patients with upper gastrointestinal hemorrhage over a 4-year period in a tertiary referral hospital. [ncbi.nlm.nih.gov]

The epidemiology is changing with more complex older patients on anticoagulant and antithrombotic agents presenting with upper gastrointestinal bleeding. [books.google.de]

Pathophysiology of Gastric Ulcer Development and Healing: Molecular Mechanisms and Novel Therapeutic Options. Peptic Ulcer Disease. 2011;10:5772-749. [ Links ] 35 Liu Y. [scielo.cl]

Aetiology of UGI haemorrhage Oesophagus Oesophageal varices Oesophagitis Oesophageal carcinoma Mallory-Weiss tear Stomach Gastric ulcer Gastritis Gastric carcinoma Duodenum Duodenal ulcer Duodenitis Other Thrombocytopenia Coagulopathy Aorto-enteric fistula Pathophysiology [oxfordmedicaleducation.com]

Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. J Crit Care. 2005 Mar. 20(1):35-45. [Medline]. Cameron JL, ed. Current Surgical Therapy. 5th ed. St. Louis, Mo: Mosby-Year Book; 1995. [emedicine.com]

This article focuses on assessment of adults with acute nonvariceal upper GI bleeding, reviews the differential diagnosis and pathophysiology of common causes, and describes guidelines for selecting appropriate diagnostic tests and evidence-based therapeutic [journals.lww.com]

H. pylori eradication treatment was more effective than placebo for the primary prevention of endoscopic PU and for the prevention of re-bleeding from PU in NSAID users. [ncbi.nlm.nih.gov]

The data here is strong, with a NNT of 1 in 22 to prevent death and 1 in 4 to prevent infectious complications [6]. [emergencymedicinecases.com]

1. Lirio RA. Management of Upper Gastrointestinal Bleeding in Children: Variceal and Nonvariceal. Gastrointest Endosc Clin N Am. 2016;26(1):63-73.
2. Wilkins T, Khan N, Nabh A, Schade RR. Diagnosis and Management of Upper Gastrointestinal Bleeding. Am Fam Physician. 2012;85(5):469-476.
3. Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1995;90(2):206–210.
4. Sánchez-Delgado J, Gené E, Suárez D, et al. Has H. pylori prevalence in bleeding peptic ulcer been underestimated? A meta-regression. Am J Gastroenterol. 2011;106(3):398–405.
5. Cheung FK, Lau JY. Management of massive peptic ulcer bleeding. Gastroenterol Clin North Am. 2009;38(2):231-243.
6. al-Assi MT, Genta RM, Karttunen TJ, Graham DY. Ulcer site and complications: relation to Helicobacter pylori infection and NSAID use. Endoscopy. 1996;28(2):229-233.
7. Peter DJ, Dougherty JM. Evaluation of the patient with gastrointestinal bleeding: an evidence based approach. Emerg Med Clin North Am. 1999;17(1):239-261.
8. Zimmerman J, Siguencia J, Tsvang E, Beeri R, Arnon R. Predictors of mortality in patients admitted to hospital for acute upper gastrointestinal hemorrhage. Scand J Gastroenterol. 1995;30(4):327–331.
9. van Leerdam ME, Vreeburg EM, Rauws EA, et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterol. 2003;98(7):1494–1499.
10. Schenker MP, Majdalany BS, Funaki BS, et al. ACR Appropriateness Criteria® upper gastrointestinal bleeding. J Am Coll Radiol. 2010;7(11):845-853.
11. Chandran S, Testro A, Urquhart P, et al. Risk stratification of upper GI bleeding with an esophageal capsule. Gastrointest Endosc. Gastrointest Endosc. 2013;77(6):891-898.
12. Frattaroli FM, Casciani E, Spoletini D, et al. Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding. World J Surg. 2009; 33(10):2209-2217.