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Bleeding from the gastrointestinal (GI) tract may present in five ways. Hematemesis is vomitus of red blood or “coffee-grounds” material. Melena is black, tarry, foul-smelling stool. Hematochezia is the passage of bright red or maroon blood from the rectum. Occult GI bleeding (GIB) may be identified in the absence of overt bleeding by a fecal occult blood test or the presence of iron deficiency. Finally, patients may present only with symptoms of blood loss or anemia such as lightheadedness, syncope, angina, or dyspnea.

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Sources of Gastrointestinal Bleeding

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Upper Gastrointestinal Sources of Bleeding

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(Table 41-1) The annual incidence of hospital admissions for upper GIB (UGIB) in the United States and Europe is ∼0.1%, with a mortality rate of ∼5–10%. Patients rarely die from exsanguination; rather, they die due to decompensation from other underlying illnesses. The mortality rate for patients <60 years in the absence of major concurrent illness is <1%. Independent predictors of rebleeding and death in patients hospitalized with UGIB include increasing age, comorbidities, and hemodynamic compromise (tachycardia or hypotension).

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Table 41-1 Sources of Bleeding in Patients Hospitalized for Upper GI Bleeding 
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Peptic ulcers are the most common cause of UGIB, accounting for up to ∼50% of cases; an increasing proportion is due to nonsteroidal anti-inflammatory drugs (NSAIDs), with the prevalence of Helicobacter pylori decreasing. Mallory-Weiss tears account for ∼5–10% of cases. The proportion of patients bleeding from varices varies widely from ∼5 to 40%, depending on the population. Hemorrhagic or erosive gastropathy (e.g., due to NSAIDs or alcohol) and erosive esophagitis often cause mild UGIB, but major bleeding is rare.

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Peptic Ulcers
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In addition to clinical features, characteristics of an ulcer at endoscopy provide important prognostic information. One-third of patients with active bleeding or a nonbleeding visible vessel have further bleeding that requires urgent surgery if they are treated conservatively. These patients clearly benefit from endoscopic therapy with bipolar electrocoagulation; heater probe; injection therapy (e.g., absolute alcohol, 1:10,000 epinephrine); and/or clips with reductions in bleeding, hospital stay, mortality rate, and costs. In contrast, patients with clean-based ulcers have rates of recurrent bleeding approaching zero. If there is no other reason for hospitalization, such patients may be discharged on the first hospital day, following stabilization. Patients without clean-based ulcers should usually remain in the hospital for three days because most episodes of recurrent bleeding occur within three days.

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Randomized controlled trials document that a high-dose, constant-infusion IV proton ...

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