Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 15-07: Gastrointestinal Bleeding + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 + Treatment Download Section PDF Listen +++ +++ 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 + Outcome Download Section PDF Listen +++ +++ 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 + References Download Section PDF Listen +++ + +Abougergi MS et al. Thirty-day readmission among patients with non-variceal upper gastrointestinal hemorrhage and effects on outcomes. Gastroenterology. 2018 Jul;155(1):38–46. [PubMed: 29601829] + +Jairath V et al. Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TRIGGER): a pragmatic, open-label, cluster randomized feasibility trial. Lancet. 2015 Jul 11;386(9989):137–44. [PubMed: 25956718] + +Rogers KC et al. A new option for reversing the anticoagulant effect of Factor Xa inhibitors: andexanet alfa (ANDEXXA). Am J Med. 2019 Jan;132(1):38–41. [PubMed: 30053385] + +Stanley AJ et al. Management of acute upper gastrointestinal bleeding. BMJ. 2019 Mar 25;364:l536. [PubMed: 30910853]