Upper gastrointestinal 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
duodenumThe duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...
to the
diaphragmIn the anatomy of mammals, the thoracic diaphragm, or simply the diaphragm , is a sheet of internal skeletal muscle that extends across the bottom of the rib cage. The diaphragm separates the thoracic cavity from the abdominal cavity and performs an important function in respiration...
near the
splenic flexureThe splenic flexure is a sharp bend between the transverse and the descending colon in the left upper quadrant of humans. The left colic flexure is near the spleen, and hence called the splenic flexure. There are two colic flexures in the transverse colon — the other being the hepatic...
of the
colonThe colon is the last part of the digestive system in most vertebrates; it extracts water and salt from solid wastes before they are eliminated from the body, and is the site in which flora-aided fermentation of unabsorbed material occurs. Unlike the small intestine, the colon does not play a...
.
Upper GI bleeds are considered medical emergencies, and require admission to
hospitalA hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
for urgent diagnosis and management. Due to advances in medications and
endoscopyEndoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
, upper GI hemorrhage is now usually treated without surgery.
Presentation
Patients with upper GI hemorrhage often present with
hematemesisHematemesis or haematemesis is the vomiting of blood. The source is generally the upper gastrointestinal tract. Patients can easily confuse it with hemoptysis , although the latter is more common.-Signs:...
,
coffee ground vomitingCoffee ground vomitus refers to a particular appearance of vomit. Blood contains iron within heme molecules in red blood cells. When this iron has been exposed to gastric acid for some time, it becomes oxidized. This reaction causes the vomitus to look like ground coffee. Coffee-ground vomitus is...
,
melenaIn medicine, melena or melaena refers to the black, "tarry" feces that are associated with gastrointestinal hemorrhage. The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon.-Melena vs...
, or
hematocheziaHematochezia is the passage of fresh blood per anus, usually in or with stools . Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper GI bleed...
(maroon coloured stool) if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage.
Patients may also present with complications of
anemiaAnemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...
, including chest pain,
syncopeSyncope , the medical term for fainting, is precisely defined as a transient loss of consciousness and postural tone characterized by rapid onset, short duration, and spontaneous recovery due to global cerebral hypoperfusion that most often results from hypotension.Many forms of syncope are...
,
fatigueFatigue is a state of awareness describing a range of afflictions, usually associated with physical and/or mental weakness, though varying from a general state of lethargy to a specific work-induced burning sensation within one's muscles...
and shortness of breath.
The
physical examinationPhysical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
performed by the
physicianA physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
concentrates on the following things:
- Vital signs
Vital signs are measures of various physiological statistics, often taken by health professionals, in order to assess the most basic body functions. Vital signs are an essential part of a case presentation. The act of taking vital signs normally entails recording body temperature, pulse rate ,...
, in order to determine the severity of bleeding and the timing of intervention
- Abdominal
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
and rectalThe rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long...
examination, in order to determine possible causes of hemorrhage
- Assessment for portal hypertension
In medicine, portal hypertension is hypertension in the portal vein and its tributaries.It is often defined as a portal pressure gradient of 10 mmHg or greater.-Causes:Causes can be divided into prehepatic, intrahepatic, and posthepatic...
and stigmata of chronic liver diseaseCirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
in order to determine if the bleeding is from a variceal source.
Laboratory findings include
anemiaAnemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...
,
coagulopathyCoagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
, and an elevated
BUN-to-creatinine ratioIn medicine, the BUN-to-creatinine ratio is the ratio of two serum laboratory values, the blood urea nitrogen and serum creatinine . Outside the United States, particularly in Canada and Europe, the truncated term urea is used and the units are different...
.
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 GI hemorrhage. Causes are usually anatomically divided into their location in the upper gastrointestinal tract.
People are usually stratified into having either
varicealIn medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...
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
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
causes:
- Esophageal varices
In medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...
- Esophagitis
Esophagitis is inflammation of the esophagus. It may be acute or chronic. The acute esophagitis can be catarrhal or phlegmonous, whereas the chronic esophagitis may be hypertrophic or atrophic.-Infectious:...
- Esophageal cancer
Esophageal cancer is malignancy of the esophagus. There are various subtypes, primarily squamous cell cancer and adenocarcinoma . Squamous cell cancer arises from the cells that line the upper part of the esophagus...
- Esophageal ulcers
- Mallory-Weiss tear
Mallory–Weiss syndrome or gastro-esophageal laceration syndrome refers to bleeding from tears in the mucosa at the junction of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting.-Causes:...
- Gastric
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
causes:
- Gastric ulcer
- Gastric cancer
- Gastritis
Gastritis is an inflammation of the lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic...
- Gastric varices
Gastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis...
- Gastric antral vascular ectasia
*Please note that Wikipedia does not give medical advice, and that the information in this article is intended to be solely for informational purposes....
- Dieulafoy's lesion
Dieulafoy's lesion is a medical condition characterized by a large tortuous arteriole in the stomach wall that erodes and bleeds. It can cause gastric hemorrhage but is relatively uncommon. It is thought to cause less than 5% of all gastrointestinal bleeds in adults...
s
- Duodenal
The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...
causes:
- Duodenal ulcer
- Vascular malformation
Vascular malformation is a term used to refer to blood vessel abnormalities. Vascular malformations and vascular tumors both belong to vascular anomaliesThere are many types, but the most common is arteriovenous 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
Hemosuccus pancreaticus, also known as pseudohematobilia or Wirsungorrhage is a rare cause of hemorrhage in the gastrointestinal tract...
, or bleeding from the pancreatic ductThe pancreatic duct, or duct of Wirsung , is a duct joining the pancreas to the common bile duct to supply pancreatic juices which aid in digestion provided by the "exocrine pancreas"...
- Severe superior mesenteric artery syndrome
Superior mesenteric artery syndrome is a very rare, life-threatening gastro-vascular disorder characterized by a compression of the third portion of the duodenum by the abdominal aorta and the overlying superior mesenteric artery...
Diagnosis
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.
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.
The nasogastric aspirate can help determine the location of bleeding and thus direct initial diagnostic and treatment plans. Witting found that nasogastric aspirate has sensitivity 42%, specificity 91%,
negative predictive valueIn statistics and diagnostic testing, the negative predictive value is a summary statistic used to describe the performance of a diagnostic testing procedure. It is defined as the proportion of subjects with a negative test result who are correctly diagnosed. A high NPV means that when the test...
64%, positive predictive value 92% and overall accuracy of 66% in differentiating upper GI bleeding from bleeding distal to the ligament of Treitz. Thus, in this study a positive aspirate is more helpful than a negative aspirate. In a smaller study, Cuellar found a sensitivity of 79% and specificity of 55%, somewhat opposite results from Witting. Cuellar also studied the appearance of the aspirate and a
summary of these results is available at the Evidence-Based On-Call database. Although the website lists these results as expired, they were available as of Oct, 16, 2006. These results are also available through the
Wayback Archive and readers may consult the Archive if the original page is removed.
Determining 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
. Cuellar found the following results:
Determining whether blood is in the gastric aspirate
| Finding | Sensitivity | Specificity | Positive predictive value
(prevalence of 39%) | Negative predictive value
(prevalence of 39%) |
| Gastroccult |
95% |
82% |
77% |
96% |
| Physician assessment |
79% |
55% |
53% |
20% |
Holman used simulated gastric specimens and found the Hemoccult test to have significant problems with non-specificy and false-positive results, whereas the Gastroccult test was very accurate
.
Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on
all control samples.
In a study published regarding a new scoring system called the
Glasgow-BlatchfordThe Glasgow-Blatchford bleeding score is a screening tool to assess the likelihood that a patient with an acute upper gastrointestinal bleeding will need to have medical intervention such as a blood transfusion or endoscopic intervention...
bleeding score in
Lancet on January 3, 2009, 16% of patients presenting with upper GI bleed had GBS score of "0", considered low. Among these patients there were no deaths or interventions needed and the patients were able to be effectively treated in an outpatient setting.
Score is equal to "0" if the following are all present:
- Hemoglobin level >12.9 g/dL (men) or >11.9 g/dL (women)
- Systolic blood pressure >109 mm Hg
- Pulse <100/minute
- Blood urea nitrogen level <18.2 mg/dL
- No melena or syncope
- No past or present liver disease or heart failure
Bayesian calculations
The predictive values cited are based on the prevalences of upper GI bleeding in the corresponding studies. A
clinical calculator can be used to generate predictive values for other prevalences.
Treatment
Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions, and
bloodBlood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
products if required. As patients with
esophageal varicesIn medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...
typically have coagulopathy,
plasmaThe term fresh frozen plasma refers to the liquid portion of human blood that has been frozen and preserved after a blood donation and will be used for blood transfusion...
products may have to be administered. Vital signs are continuously monitored.
Early
endoscopyFor other expansions of the initialism "OGD", see the disambiguation page.In medicine , esophagogastroduodenoscopy is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum...
is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the type of lesion identified, and can include:
- injection
An injection is an infusion method of putting fluid into the body, usually with a hollow needle and a syringe which is pierced through the skin to a sufficient depth for the material to be forced into the body...
of adrenaline or other sclerotherapySclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations...
- electrocautery
- endoscopic clipping
- or banding of varices
In medicine , esophageal varices are extremely dilated sub-mucosal veins in the lower esophagus...
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
Gastric acid is a digestive fluid, formed in the stomach. It has a pH of 1 to 2 and is composed of hydrochloric acid , and large quantities of potassium chloride and sodium chloride...
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
Octreotide is an octapeptide that mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of growth hormone, glucagon, and insulin than the natural hormone...
is a somatostatinSomatostatin is a peptide hormone that regulates the endocrine system and affects neurotransmission and cell proliferation via interaction with G-protein-coupled somatostatin receptors and inhibition of the release of numerous secondary hormones.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
Terlipressin is an analogue of vasopressin used as a vasoactive drug in the management of hypotension. It has been found to be effective when norepinephrine does not help.Indications for use include norepinephrine-resistant septic shock and hepatorenal syndrome...
is a vasopressinArginine vasopressin , also known as vasopressin, argipressin or antidiuretic hormone , is a neurohypophysial hormone found in most mammals, including humans. Vasopressin is a peptide hormone that controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue's...
analog most commonly used in Europe for variceal upper GI hemorrhage.
- Antibiotics are prescribed in upper GI bleeds associated with portal hypertension
In medicine, portal hypertension is hypertension in the portal vein and its tributaries.It is often defined as a portal pressure gradient of 10 mmHg or greater.-Causes:Causes can be divided into prehepatic, intrahepatic, and posthepatic...
If
Helicobacter pyloriHelicobacter pylori , previously named Campylobacter pyloridis, is a Gram-negative, microaerophilic bacterium found in the stomach. It was identified in 1982 by Barry Marshall and Robin Warren, who found that it was present in patients with chronic gastritis and gastric ulcers, conditions that were...
is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested.
Refractory bleeding
Refractory cases of upper GI hemorrhage may require:
- Repeat esophagogastroduodenoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
- Anti-fibrinolytics, such as tranexamic acid
Tranexamic acid is a drug used to treat or prevent excessive blood loss during surgery and in certain other conditions...
- Angiography to identify and possibly occlude the feeder vessel
- Recombinant Factor VII
Factor VII is one of the proteins that causes blood to clot in the coagulation cascade. It is an enzyme of the serine protease class. A recombinant form of human factor VIIa has U.S. Food and Drug Administration approval for uncontrolled bleeding in hemophilia patients...
is sometimes used as an adjunct in refractory bleeding, but its utility has only been tested for variceal hemorrhage
- Balloon tamponade
Balloon tamponade usually refers to the use of balloons inserted into the esophagus or stomach, and inflated to stop refractory bleeding from vascular structures—including esophageal varices and gastric varices -- in the upper gastrointestinal tract....
- Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
, to oversew or remove the area of hemorrhage
Certain causes of upper GI hemorrhage (including gastric ulcers require repeat
endoscopyEndoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
after the episode of bleeding to ascertain healing of the causative lesion.
Epidemiology
About 75% of patients presenting to the emergency room with GI bleeding have an upper source
. The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of patients in the emergency room with GI bleeding have an upper source
External links