Gastrointestinal Bleeding, Acute Upper

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

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)

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 a rubber band or metallic clips

Medications

• Intravenous proton pump inhibitor (eg, esomeprazole or pantoprazole 80-mg bolus, followed by 8 mg/hour continuous infusion for 72 hours) reduces risk of rebleeding in patients with peptic ulcers with high-risk features (active bleeding, visible vessel, or adherent clot) after endoscopic treatment

• Oral proton pump inhibitors (omeprazole, esomeprazole, or pantoprazole 40 mg, lansoprazole or dexlansoprazole 30–60 mg, once or twice daily) are sufficient for lesions at low-risk for rebleeding (esophagitis, gastritis, clean-based ulcers, and Mallory-Weiss tears)

• Octreotide, 100-mcg bolus, followed by 50–100 mcg/h, for bleeding related to portal hypertension

• In countries where it is available, terlipressin may be preferred to octreotide to treat bleeding related to portal hypertension

• Uremic patients with active bleeding should be given 3 doses of desmopressin (DDAVP), 0.3 mcg/kg intravenously at 12-hour intervals

• Direct thrombin inhibitor (dabigatran) or factor Xa inhibitors (rivaroxaban, apixaban, edoxaban)

  • Normal anticoagulation is usually restored within 24–48 hours in patients with normal kidney and liver function

  • Reversal should only be considered for life- threatening bleeding

    • Idarucizumab is approved for the reversal of dabigatran

    • Andexanet alfa is approved for the reversal of apixaban and rivaroxaban

Therapeutic Procedures

• Insert two 18-gauge or larger intravenous lines

• In patients without hemodynamic compromise or overt active bleeding, aggressive fluid repletion can be delayed until extent of bleeding is clarified

• Patients with hemodynamic compromise should be given 0.9% saline or lactated Ringer injection and cross-matched for 2–4 units of packed red blood cells

• Nasogastric tube placed for aspiration

• Blood replacement to maintain a hemoglobin of 7–8 g/dL

• In the absence of continued bleeding, the hematocrit should rise 4% for each unit of transfused packed red cells

• Transfuse blood in patients with massive active bleeding regardless of the hematocrit

• Transfuse platelets if platelet count < 50,000/mcL or if impaired platelet function due to aspirin or clopidogrel use

• Fresh frozen plasma or four factor prothrombin complex (Kcentra) may be administered to patients with active bleeding who are taking warfarin or other anticoagulants and have an INR > 2.5

• In general, endoscopy may be performed safely and effective hemostasis treatment applied if the INR is < 2.5

• In massive bleeding, administration of four factor prothrombin complex concentrates is preferred over fresh frozen plasma because it is more rapid and effective at correcting the INR and requires a smaller volume

• Intra-arterial embolization in patients who are poor operative risks and who have persistent bleeding from ulcers, angiomas, or Mallory-Weiss tears and in whom endoscopic therapy has failed

• Transvenous intrahepatic portosystemic shunts (TIPS) to decompress the portal venous system and control acute variceal bleeding are indicated in patients in whom endoscopic modalities have failed

Prognosis

• Mortality rate for nonvariceal upper gastrointestinal bleeding has declined steadily over the past 20 years to 2.1% in 2009

• Hemorrhage from peptic ulcers has an overall mortality rate of 5%

• Portal hypertension has a hospital mortality rate of 15%; mortality rate is 60–80% at 1–4 years

When to Refer

• Refer to gastroenterologist for endoscopy

• Refer to surgeon for uncontrollable, life-threatening hemorrhage

When to Admit

• Very low-risk patients who meet the following criteria do not require hospital admission and can be evaluated as outpatients

  • No serious comorbid medical illnesses or advanced liver disease and normal hemodynamic status

  • No evidence of overt bleeding (hematemesis or melena) within 48 hours

  • Negative nasogastric lavage

  • Normal laboratory tests

• Low- to moderate-risk patients are admitted to hospital

  • For upper endoscopy after appropriate stabilization and further treatment

  • Based on findings, may then be discharged and monitored as outpatients

• High-risk patients with any of the following require ICU admission

  • Active bleeding manifested by hematemesis or bright red blood in nasogastric aspirate

  • Shock

  • Persistent hemodynamic derangement despite fluid resuscitation

  • Serious comorbid medical illness

  • Evidence of advanced liver disease