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]

  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". [en.wikipedia.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]

• 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]

  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]

• 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]

  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]

  "ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis". Am J Emerg Med. 24 (3): 280–5. doi:10.1016/j.ajem.2005.11.005. [en.wikipedia.org]

• 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]

  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]

  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]

  […] 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]

• 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]

  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]

  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]

  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]

  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]

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]

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