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Essentials of Diagnosis
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Upper gastrointestinal (GI) hemorrhage, with "coffee grounds" emesis, hematemesis, melena, or hematochezia
Perforation, with severe pain and peritonitis
Penetration, with severe pain and pancreatitis
Gastric outlet obstruction, with vomiting
Emergent upper endoscopy is usually diagnostic and sometimes therapeutic
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General Considerations
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~50% of upper GI bleeding is due to peptic ulcer disease
Bleeding occurs in 10% of patients with an ulcer
Bleeding stops spontaneously in about 80% of patients; the remainder have severe bleeding
Overall mortality rate for ulcer bleeding is 7%
Mortality rate is higher in
The elderly
Those with comorbid medical problems
Those with hospital-associated bleeding, persistent hypotension, or shock
Those with bright red blood in the vomitus or nasogastric lavage fluid
Those with severe coagulopathy
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GASTRIC OUTLET OBSTRUCTION
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Up to 20% have no antecedent pain
Presents with "coffee grounds" emesis, hematemesis, melena, or hematochezia
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May present with sudden, severe abdominal pain
Elderly or debilitated patients and those receiving long-term corticosteroid therapy may have minimal initial symptoms
Bacterial peritonitis, sepsis, and shock may present later and then patients appear ill, with a rigid, quiet abdomen and rebound tenderness, hypotension
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Pain is severe and constant, may radiate to the back, and is unresponsive to antacids or food
Physical examination is nonspecific
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GASTRIC OUTLET OBSTRUCTION
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Causes symptoms of early satiety, vomiting, and weight loss
Early symptoms: epigastric fullness or heaviness after meals
Later symptoms: after eating, vomiting of partially digested food contents
Chronic obstruction: a grossly dilated, atonic stomach, severe weight loss, and malnutrition, dehydration
Succussion splash in the epigastrium
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Differential Diagnosis
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Upper GI bleeding
Severe epigastric pain
Esophageal rupture
Gastric volvulus
Cholecystitis
Acute pancreatitis
Small bowel obstruction
Appendicitis
Ureteral colic
Splenic rupture
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UPPER GI HEMORRHAGE
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