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PRESENTATION

  1. Hematemesis: Vomiting of blood or altered blood (“coffee grounds”) indicates bleeding proximal to ligament of Treitz.

  2. Melena: Altered (black) blood per rectum (>100 mL blood required for one melenic stool) usually indicates bleeding proximal to ligament of Treitz but may be as distal as ascending colon; pseudomelena may be caused by ingestion of iron, bismuth, licorice, beets, blueberries, charcoal.

  3. Hematochezia: Bright red or maroon rectal bleeding usually implies bleeding beyond ligament of Treitz but may be due to rapid upper GI bleeding (>1000 mL).

  4. Positive fecal occult blood test with or without iron deficiency.

  5. Symptoms of blood loss: e.g., light-headedness or shortness of breath.

HEMODYNAMIC CHANGES

Orthostatic drop in BP >10 mmHg usually indicates >20% reduction in blood volume (± syncope, light-headedness, nausea, sweating, thirst).

SHOCK

BP <100 mmHg systolic usually indicates <30% reduction in blood volume (± pallor, cool skin).

LABORATORY CHANGES

Hematocrit may not reflect extent of blood loss because of delayed equilibration with extravascular fluid. Mild leukocytosis and thrombocytosis. Elevated blood urea nitrogen is common in upper GI bleeding.

ADVERSE PROGNOSTIC SIGNS

Age >60, associated illnesses, coagulopathy, immunosuppression, presentation with shock, rebleeding, onset of bleeding in hospital, variceal bleeding, endoscopic stigmata of recent bleeding [e.g., “visible vessel” in ulcer base (see below)].

UPPER GI BLEEDING

CAUSES

Common

Peptic ulcer (accounts for ~50%), gastropathy [alcohol, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), stress], esophagitis, Mallory-Weiss tear (mucosal tear at gastroesophageal junction due to retching), gastroesophageal varices.

Less Common

Swallowed blood (nosebleed); esophageal, gastric, or intestinal neoplasm; anticoagulant and fibrinolytic therapy; hypertrophic gastropathy (Ménétrier's disease); aortic aneurysm; aortoenteric fistula (from aortic graft); arteriovenous malformation; telangiectases (Osler-Rendu-Weber syndrome); Dieulafoy lesion (ectatic submucosal vessel); vasculitis; connective tissue disease (pseudoxanthoma elasticum, Ehlers-Danlos syndrome); blood dyscrasias; neurofibroma; amyloidosis; hemobilia (biliary origin).

EVALUATION

After hemodynamic resuscitation (see below and Fig. 47-1).

FIGURE 47-1

Suggested algorithm for pts with acute upper GI bleeding. Recommendations on level of care and time of discharge assume pt is stabilized without further bleeding or other concomitant medical problems. ICU, intensive care unit; PPI, proton pump inhibitor.

  • History and physical examination: Drugs (increased risk of upper and lower GI tract bleeding with aspirin and NSAIDs), prior ulcer, bleeding history, family history, features of cirrhosis or vasculitis, etc. Hyperactive bowel sounds favor upper GI source.

  • Nasogastric aspirate for gross blood, if source (upper versus lower) not clear from history; may be falsely negative in up to 16% of pts if bleeding has ceased or duodenum is the source. Testing aspirate for occult blood is meaningless.

  • Upper endoscopy: Accuracy >90%; allows visualization of bleeding site and possibility of therapeutic ...

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