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Key Features

Essentials of Diagnosis

  • Hematemesis (bright red blood or "coffee grounds")

  • Melena in most cases; hematochezia in massive upper GI bleeding

  • Use volume (hemodynamic) status to determine severity of blood loss; hematocrit is a poor early indicator of blood loss

  • Endoscopy is diagnostic and may be therapeutic

General Considerations

  • Most common presentation is hematemesis or melena; hematochezia in 10% with massive bleeding

  • Hematemesis is either bright red blood or brown "coffee grounds" material

  • Melena develops after as little as 50–100 mL of blood loss

  • Hematochezia requires > 1000 mL of blood loss

  • Upper GI bleeding is self-limited in 80% of cases; urgent medical therapy and endoscopic evaluation are required in the remainder

  • Bleeding > 48 hours prior to presentation carries a low risk of recurrent bleeding

  • Peptic ulcers account for 40% of cases

  • Portal hypertension bleeding (10–20% of cases) occurs from varices (most commonly esophageal)

  • Mallory-Weiss tears are lacerations of the gastroesophageal junction (5–10% of cases)

  • Vascular anomalies account for 7% of cases

    • Angioectasias

      • Most common

      • 1–10 mm distorted, aberrant submucosal vessels

      • Have bright red stellate appearance

      • Occur throughout GI tract but most commonly in right colon

    • Telangiectasias

      • Small, cherry red lesions

      • Occur sporadically

    • Dieulafoy lesion

      • Aberrant, large caliber submucosal artery

      • Most commonly in proximal stomach

      • Causes recurrent, intermittent bleeding

  • Gastric neoplasms (1% of cases)

  • Erosive gastritis (< 5% of cases) due to nonsteroidal anti-inflammatory drugs (NSAIDs), alcohol, or severe medical or surgical illness (stress-related mucosal disease)

Demographics

  • 250,000 hospitalizations a year in the United States

Clinical Findings

Symptoms and Signs

  • Signs of chronic liver disease implicate bleeding due to portal hypertension, but a different lesion is identified in 25% of patients with cirrhosis

  • Dyspepsia, NSAID use, or history of previous peptic ulcer suggests peptic ulcer disease

  • Heavy alcohol ingestion or retching suggests a Mallory-Weiss tear

Differential Diagnosis

  • Hemoptysis

  • Peptic ulcer disease

  • Esophageal or gastric varices

  • Erosive gastritis, eg, NSAIDs, alcohol, stress

  • Mallory-Weiss syndrome

  • Portal hypertensive gastropathy

  • Angioectasias (angiodysplasias), eg, idiopathic arteriovenous malformation, CREST syndrome, hereditary hemorrhagic telangiectasias

  • Gastric cancer

  • Rare causes

    • Erosive esophagitis

    • Duodenal varices

    • Aortoenteric fistula

    • Dieulafoy lesion (aberrant gastric submucosal artery)

    • Hemobilia (from hepatic tumor, angioma, penetrating trauma)

    • Pancreatic cancer

    • Hemosuccus pancreaticus (pancreatic pseudoaneurysm)

Diagnosis

Laboratory Tests

  • Complete blood count

  • Platelet count

  • Prothrombin time/INR

  • Serum creatinine

  • Liver enzymes

  • Blood type and crossmatch

  • Hematocrit is a poor early indicator of the severity of acute bleeding

Diagnostic Procedures

  • Assess volume (hemodynamic) status

    • Systolic blood pressure

    • Heart rate

    • Postural hypotension

  • Upper endoscopy after the patient is hemodynamically stable

    • To identify the source of bleeding

    • To determine the risk of rebleeding and guide triage

    • To render endoscopic therapy such as cautery or injection of a sclerosant or epinephrine or application of ...

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