Gastrointestinal Bleeding, Acute Upper

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

• Over 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 ...