Upper gastrointestinal bleeding

Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon.

Upper GI bleeds are considered medical emergencies, and require admission to hospital for urgent diagnosis and management. Due to advances in medications and endoscopy, upper GI hemorrhage is now usually treated without surgery.

Clinical presentation

Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, maroon stool, or hematochezia if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage.

Patients 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

There are many causes for upper GI hemorrhage. Causes are usually anatomically divided into their location in the upper gastrointestinal tract.

Patients are usually stratified into having either variceal or non-variceal sources of upper GI hemorrhage, as the two have different treatment algorithms and prognosis.

The causes for upper GI hemorrhage include the following:
*Esophageal causes:
** Esophageal varices
** Esophagitis
** Esophageal cancer
**Esophageal ulcers

*Gastric causes:
** Gastric ulcer
** Gastric cancer
** Gastritis
** Gastric varices
** Gastric antral vascular ectasia, or watermelon stomach
** Dieulafoy's lesions

*Duodenal causes:
**Duodenal ulcer
** Vascular malformations, 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.cite journal |author=Graber CJ et al |title=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 |journal=New Engl J Med |volume=357 |issue= |pages=1029–34 |year=2007|doi=10.1056/NEJMcps062601|url=http://content.nejm.org/cgi/content/full/357/10/1029 |pmid=17804848] cite journal |author=Sierra J, Kalangos A, Faidutti B, Christenson JT |title=Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy |journal=Cardiovascular surgery (London, England) |volume=11 |issue=3 |pages=185–8 |year=2003 |pmid=12704326 |doi=] cite journal |author=Cendan JC, Thomas JB, Seeger JM |title=Twenty-one cases of aortoenteric fistula: lessons for the general surgeon |journal=The American surgeon |volume=70 |issue=7 |pages=583–7; discussion 587 |year=2004 |pmid=15279179 |doi=]
** Hematobilia, or bleeding from the biliary tree
**Hemosuccus pancreaticus, or bleeding from the pancreatic duct

Diagnosis

ummary

The diagnosis of upper GI bleeding is assumed when hematemesis is documented. 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. In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using the Gastroccult test.

[cite journal |author=Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M |title=Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis |journal=Ann Emerg Med |volume=43 |issue=4 |pages=525–32 |year=2004 |pmid=15039700 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0196064403009417 ] cite journal |author=Cuellar RE, Gavaler JS, Alexander JA, "et al" |title=Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate |journal=Arch. Intern. Med. |volume=150 |issue=7 |pages=1381–4 |year=1990 |pmid=2196022 |doi= |url=] . Determining whether a patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult.

Diagnostic testing

Whiting studied a cohort of 325 patients and found the odds ratios for the strongest predictors were: black stool, 16.6 (95% confidence interval [CI] , 7.7-35.7); age < 50 years, 8.4 (95% CI, 3.2-22.1); and blood urea nitrogen/creatinine ratio 30 or more, 10.0 (95% CI, 4.0-25.6). Seven (5%) of 151 with none of these factors had an upper GI tract bleed, versus 63 (93%) of 68 with 2 or 3 factors. Ernst found similar results

INDICATIONDetermining whether blood is in gastric contents, either vomited or aspirated specimens, is surprisingly difficult. Slide tests are based on orthotolidine (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). Rosenthal found 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 [cite journal |author=Rosenthal P, Thompson J, Singh M |title=Detection of occult blood in gastric juice |journal=J. Clin. Gastroenterol. |volume=6 |issue=2 |pages=119–21 |year=1984 |pmid=6715849 |doi= |url=] . Cuellar found the following results:

{| class="wikitable" style="text-align:center"
+ Determining whether blood is in the gastric aspirate! Finding !! Sensitivity !! Specificity !! Positive predictive value
(prevalence of 39%)!! Negative predictive value
(prevalence of 39%)

Treatment

Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions, and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to be administered. Vitals signs are continuously monitored.

Early endoscopy is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the lesion identifies, and can include:

*injection of adrenaline or other sclerotherapy
*electrocautery
*endoscopic clipping
*or banding of varices

Stigmata of high risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding.

Pharmacotherapy includes the following:
* Proton pump inhibitors (PPIs), which reduce gastric acid production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage. These can be administered orally or intravenously as an infusion depending on the risk of rebleeding.
* Octreotide is a somatostatin analog believed to shunt blood away from the splanchnic circulation. It has found to be a useful adjunct in management of both variceal and non-variceal upper GI hemorrhage. It is the somatostatin analog most commonly used in North America.
* Terlipressin is a vasopressin analog most commonly used in Europe for variceal upper GI hemorrhage.
* Antibiotics are prescribed in upper GI bleeds associated with portal hypertension

If "Helicobacter pylori" is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested.