Upper GI (UGI) bleeding is defined as bleeding
originating proximal to the ligament of Treitz.
Acute UGI bleeding in adults has an overall annual
incidence of approximately 47 per 100,000. It is more common among
males and the elderly.1 In contrast, lower GI bleeding
is considerably less common.
As with all true emergencies, the traditional triad of medical
history, physical examination, and diagnosis often must be accomplished
simultaneously with resuscitation and stabilization. Factors associated
with an increased morbidity and mortality are increasing age, coexistent
organ system disease, and recurrent hemorrhage.1
Peptic ulcer disease, including gastric, duodenal,
esophageal, and stomal ulcers, is the commonest cause of UGI bleeding.1,2
Gastritis and Esophagitis
Erosive gastritis, esophagitis, and duodenitis
together are responsible for approximately 13% of all cases
of UGI hemorrhage. Predisposing factors include alcohol, salicylates,
Esophageal and gastric varices result from portal
hypertension and, in the U.S., are most often a result of alcoholic
liver disease. Although varices account for only about 7% of
all cases of UGI hemorrhage, they are most likely to rebleed and
carry a 16% mortality rate. Nevertheless, many patients
with end-stage cirrhosis never develop varices, many patients with documented
varices never bleed, and many patients with a documented history
of varices presenting with UGI bleeding will actually be bleeding from
Mallory-Weiss syndrome is UGI bleeding secondary
to a longitudinal mucosal tear in the cardioesophageal region. The
classic history is repeated vomiting followed by bright red hematemesis,
but extreme Valsalva maneuvers, such as from coughing or seizures,
also have been reported as causes.
Stress ulcer, arteriovenous malformation, and
malignancy are other causes of UGI hemorrhage. Ear, nose, and throat
sources of bleeding can also masquerade as GI hemorrhage. An aortoenteric
fistula secondary to a preexisting aortic graft is an unusual but
important cause of bleeding to keep in mind. Classically, this presents
as a self-limited “herald” bleed, which precedes
Although the medical history may suggest the
source of bleeding, it can also be misleading. For instance, what
initially appears to be lower GI bleeding is often actually UGI
bleeding in disguise. Bright red or maroon rectal bleeding unexpectedly originates
from UGI sources about 14% of the time.3 Although
most patients will volunteer complaints of hematemesis or melena,
UGI bleeding may also be subtle. Patients with hypotension, tachycardia,
angina, syncope, weakness, confusion, or cardiac arrest may have
underlying GI hemorrhage.
Ask about hematemesis, coffee-ground emesis,
or melena. Classically, hematemesis and coffee-ground emesis suggests
an UGI source. In patients without a history of hematemesis, the
presence of melena and an age <50 years old suggest an UGI source.4 Vomiting
and retching, followed by hematemesis, suggests a Mallory-Weiss
tear. A history of an aortic graft should suggest bleeding from
an aortoenteric fistula. Ask about medications, particularly salicylates,
glucocorticoids, NSAIDs, and anticoagulants. Alcohol abuse is strongly
associated with a number of causes of UGI bleeding, including peptic
ulcer disease, erosive gastritis, and esophageal varices. Ingestion
of iron or bismuth can simulate melena, and certain foods, such
as beets, can simulate hematochezia. In such cases, stool guaiac
testing will be negative. A past history of GI bleeding should also
be sought, even though recurrent bleeding episodes often originate
from different sources.
The vital signs may reveal obvious hypotension
and tachycardia or more subtle findings such as decreased pulse
pressure or tachypnea. Some patients can tolerate substantial volume
loss with minimal or no changes in vital signs. Paradoxical bradycardia can
occur even in the face of profound hypovolemia.
Cool, clammy skin is an obvious sign of shock.
Spider angiomata, palmar erythema, jaundice, and gynecomastia suggest
liver disease. Petechiae and purpura suggest an underlying coagulopathy.
Skin findings may be suggestive of the Peutz-Jeghers, Rendu-Osler-Weber,
or Gardner syndromes. A careful ear, nose, and throat examination
will occasionally reveal an occult bleeding source that has resulted
in swallowed blood and subsequent coffee-ground emesis or melena.
The abdominal examination may disclose tenderness, masses, ascites,
or organomegaly. A rectal examination is indicated to detect the
presence of blood and its appearance (bright red, maroon, or melanotic).
In patients with significant UGI bleeding, the
most important laboratory test is to type and cross-match blood.
Another important test is a complete blood count, although the initial
hematocrit level often will not reflect the actual amount of blood
loss. In addition, blood urea nitrogen (BUN), creatinine, electrolyte,
glucose, coagulation, and liver function studies should be considered.
Upper tract hemorrhage may elevate BUN levels through digestion
and absorption of hemoglobin, and a BUN:creatinine ratio ≥30 is
suggestive of a UGI source of bleeding.4 Coagulation
studies, including international normalized ratio, partial thromboplastin
time, and platelet count, are of obvious benefit in patients taking
anticoagulants or those with underlying hepatic disease. An ECG
should be considered in patients statistically likely to have coronary
artery disease, as silent ischemia can occur secondary to the decreased
oxygen delivery accompanying significant GI bleeding. Supplemental
oxygen is advised for such patients.
UGI endoscopy is the diagnostic study of choice
in the evaluation of presumed UGI bleeding (see Treatment, Endoscopy below).
Nasogastric (NG) intubation is recommended in most patients with
significant GI bleeding,5 and may have both diagnostic
and therapeutic benefits. However, NG intubation is exceedingly
uncomfortable, and the use of topical anesthesia is advised.6 In
patients with a clear-cut history of hematemesis, an NG tube can
assess the presence of ongoing active bleeding, as well as help
prepare the patient for endoscopy. ...