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Upper Gastrointestinal Bleeding

Upper Gastrointestinal Hemorrhage

Upper gastrointestinal hemorrhage is bleeding that occurs at a site proximal to the ligament of Treitz. This life-threatening event is frequently a consequence of peptic ulcer disease although there are other causes as well. The clinical presentation features primarily hematemesis, melena, and epigastric pain.


Gastric ulcer 2
Gastric ulcer 2
Gastric ulcer 2, CC BY-SA 3.0

Presentation

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]
  • Arteriovenous malformations of the stomach are rare; blood loss may be manifested either by chronic anemia or by massive recurrent hemorrhage.[ncbi.nlm.nih.gov]
  • We report a case of an unusually large Brunneroma in a patient who presented with fresh melena and anemia.[ncbi.nlm.nih.gov]
  • A 36-year-old male Asian immigrant with a history of hepatitis B and hepatitis C related unresectable hepatocellular carcinoma in the left lobe of the liver presented with hematemesis and severe anemia.[ncbi.nlm.nih.gov]
  • Patients were more often elderly women with chronic anemia, always had large hiatal hernias, and were usually referred for obscure GIH.[ncbi.nlm.nih.gov]
Fever
  • Abstract Gastrointestinal (GI) hemorrhage is not a common complication of Mediterranean spotted fever (MSF).[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • […] 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]
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]
  • "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".[ipfs.io]
  • 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]
  • Fever and chills support infectious or inflammatory causes. A history of vomiting, coughing, or retching suggests Mallory-Weiss syndrome (bleeding from a mucosal tear at the gastroesophageal junction).[journals.lww.com]
Pallor
  • 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]
  • 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]
  • 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]
Rigor
  • […] more have at least a 10% mortality rate and should undergo urgent endoscopy and be admitted to a critical care area (Grade 2a, recommendation D) Consider the use of high dose intravenous PPIs to high risk patients with upper GI bleeds despite lack of rigorous[rcemlearning.co.uk]
  • A variety of observational studies and a few randomized trials have assessed this issue, but marked variations in study design, definitions, end points, and methodologic rigor make synthesis of the results difficult.[gi.org]
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]
  • We report a case of an unusually large Brunneroma in a patient who presented with fresh melena and anemia.[ncbi.nlm.nih.gov]
  • 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.[ncbi.nlm.nih.gov]
  • 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]
  • A man with 61 years old was admitted to the emergency service sustaining hematemesis and melena. Endoscopy showed active bleeding from a tumor in the second portion of the duodenum, which was controlled by heater probe cauterization.[ncbi.nlm.nih.gov]
Hematemesis
  • All of the emergency department visits by children ages 0 to 18 years who presented with hematemesis between 2000 and 2007 were reviewed.[ncbi.nlm.nih.gov]
  • This retrospective cohort study involved patients admitted via the ED for GI tract bleeding without hematemesis, who underwent confirmatory testing.[ncbi.nlm.nih.gov]
  • 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]
  • The diagnosis is easier when the patient has hematemesis.[en.wikipedia.org]
  • A unique case of hematemesis is presented. The cause of upper gastrointestinal bleeding was a pyloroduodenal ulcer caused by erosion of a 5-cm gallstone impacted in the duodenal bulb.[ncbi.nlm.nih.gov]
Vomiting
  • 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]
  • A 74-year-old woman with a recent diagnosis of peptic ulcer disease diagnosed by endoscopy after presentation with an episode of upper gastrointestinal bleeding returned 6 1/2 weeks later with a 5-day history of nausea and vomiting without associated[ncbi.nlm.nih.gov]
  • […] hemorrhages were associated with older age (9.7 vs 2.9 years; P CONCLUSIONS: The occurrence of a clinically significant UGIH was uncommon among children with hematemesis, especially in well-appearing children without melena, hematochezia, or who had not vomited[ncbi.nlm.nih.gov]
  • Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock.[en.wikipedia.org]
  • You vomit blood or what looks like coffee grounds. You passed out (lost consciousness). Your stools are maroon or very bloody.[myhealth.alberta.ca]
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]
  • 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]
  • […] 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]
  • Patients with chronic liver disease and portal hypertension are at an increased risk for variceal hemorrhage and portal gastropathy in addition to ulcer hemorrhage.[emedicine.com]
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]
  • According to a study by Witting, the strongest predictors were of an upper GI bleed are black stool, age 50 years, and blood urea nitrogen/creatinine ratio 30 or more.[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]
  • 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]
  • 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]
  • Therefore, short-term administration of continuously infused cimetidine offers benefits in patients who have sustained major surgery, trauma, burns, hypotension, sepsis, or single organ failure.[dukespace.lib.duke.edu]
  • Circulation Assessment Observations Heart rate – tachycardia can be an early sign of volume depletion Blood pressure – hypotension doesn’t typically occur until there has been significant blood loss (1500-2000mls), so if hypotension is present this is[geekymedics.com]
  • Orthostatic hypotension signifies a total blood volume deficit of 15% or more, and supine hypotension indicates a volume loss of 40% or more. 4 Signs of chronic liver disease include jaundice, spider angiomata, palmar erythema, gynecomastia, hepatomegaly[journals.lww.com]

Workup

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]
Brain Edema
  • It generally presents as mental state changes and is usually caused by intracranial hematoma, brain edema, or swelling. Hyperammonemia can also result in postoperative coma; however, it is rarely recognized as a potential cause in coma patients.[ncbi.nlm.nih.gov]

Treatment
  • Of these, 1114 were randomised to PPI treatment and 1109 to control treatment.[doi.org]
  • , histamine-2 receptor antagonist (H2RA) or no treatment prior to endoscopy.[ncbi.nlm.nih.gov]
  • H. pylori eradication treatment was equally effective with PPI treatment for the primary or secondary prevention of endoscopic ulcers in NSAID users.[ncbi.nlm.nih.gov]
  • The GBS was superior to both the clinical Rockall and the full Rockall score in predicting the need for treatment (area under the curve: 0.86 vs. 0.70 vs. 0.77).[ncbi.nlm.nih.gov]
  • However, because of limitations in the internal and external validity of included trials, additional evidence is needed before treatment recommendations can be made.[ncbi.nlm.nih.gov]

Prognosis
  • In contrast to the acute leukemias, chronic lymphocytic leukemia (CLL) is a hematological malignancy with a generally good prognosis.[ncbi.nlm.nih.gov]
  • Shock: the presence of signs of shock at presentation confers a worse prognosis.[patient.co.uk]
  • A high index of suspicion is essential for early diagnosis and better prognosis.[ncbi.nlm.nih.gov]
  • Endoscopic therapy accompanied by medication is a standard approach that is used to improve the prognosis of UGH patients and a few medications have been developed including proton pump inhibitors (PPIs), histamine H2 receptor antagonist (H2RA), somatostatin[ncbi.nlm.nih.gov]
  • Clinical findings, endoscopic features, prognosis, rebleeding risk factors, and mortality-related factors were evaluated.[ncbi.nlm.nih.gov]

Etiology
  • Administrative data and chart review were used to identify demographics, UGH risk factors, and UGH etiologies. Bivariate and multivariate analyses were performed to describe distributions and associations of risk factors and etiologies.[ncbi.nlm.nih.gov]
  • The figures from our study are true reflection of the real etiological spectrum of UGIB in this region.[ncbi.nlm.nih.gov]
  • GOALS: To examine ethnicity's role in the etiology and outcome of upper gastrointestinal hemorrhage (UGIH). BACKGROUND: UGIH is a serious condition with considerable associated morbidity and mortality.[ncbi.nlm.nih.gov]
  • The etiology of this problem remains unknown and more work is needed so that effective preventive measures can be developed.[ncbi.nlm.nih.gov]
  • AIM: To investigate trends in etiology and outcome of UGIH in hospitalized patients in the USA. METHODS: Retrospective, observational cohort study of the Nationwide Inpatient Sample from 2002 to 2012 was carried out.[ncbi.nlm.nih.gov]

Epidemiology
  • RESULTS: The hospitalization rate of UGIH in the USA decreased by 21% from 2002 to 2012, from 81 to 67 cases per 100,000 population (p CONCLUSIONS: The epidemiology of UGIH hemorrhage appears to be shifting, with a decline in PUD and gastritis; an increase[ncbi.nlm.nih.gov]
  • 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]
  • CONCLUSIONS: Unlike older studies, PUD was not the most common etiology, suggesting that advances in Helicobacter pylori (H. pylori) eradication may affect the epidemiology of UGH.[ncbi.nlm.nih.gov]
  • From the Departments of Therapeutics and Epidemiology & Community Medicine University Hospital Nottingham UK[link.springer.com]
  • The epidemiology is changing with more complex older patients on anticoagulant and antithrombotic agents presenting with upper gastrointestinal bleeding.[books.google.de]
Sex distribution
Age distribution

Pathophysiology
  • 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]
  • 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/Diagnosis/Management, 8th edn. Saunders Elsevier: Philadelphia, 2010, pp 285–322. 47. Swain CP, Kalabakas A, Rampton DS et al.[gi.org]

Prevention
  • 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]
  • Abstract The purpose of this study was to examine the effectiveness of gastric feeding in prevention of upper gastrointestinal (GI) hemorrhage.[ncbi.nlm.nih.gov]
  • The etiology of this problem remains unknown and more work is needed so that effective preventive measures can be developed.[ncbi.nlm.nih.gov]
  • We conclude that a prophylactic regimen that reduced the amount of acid bathing the gastroduodenal mucosa, provides adequate calories, and minimizes psychic stress is useful in preventing gastrointestinal hemorrhage after burns.[ncbi.nlm.nih.gov]
  • The aim of this study was to retrospectively investigate the risk factors and prevention of upper GI bleeding after CABG. METHODS: This study followed 6316 coronary patients who underwent CABG from 1998 to 2005.[ncbi.nlm.nih.gov]

References

Article

  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.

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Last updated: 2019-06-28 09:30