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  • Patients with acute upper GI bleeding can present with hematemesis, melena, or hematochezia
  • Clinical guidelines are recommended to predict outcomes, including rebleeding, and mortality
  • Stigmata of recent hemorrhage are endoscopic findings that predict outcome
  • Endoscopy can provide the diagnosis, prognosis, and the potential for therapy

Nonvariceal upper gastrointestinal (GI) bleeding is a common reason for emergency department visits and admissions to the hospital. It has been estimated that upper GI bleeding is responsible for over 300,000 hospitalizations per year in the United States. An additional 100,000–150,000 patients per year develop upper GI bleeding during hospitalizations for other reasons.

The source of upper GI bleeding is by definition proximal to the ligament of Treitz. The natural history of nonvariceal upper GI bleeding is that approximately 80% of patients will stop bleeding spontaneously and in this group, no further urgent intervention will be needed. However, if a patient rebleeds, there is a tenfold increased mortality rate.

The overall mortality rate is 3–14% for patients with nonvariceal upper GI bleeding. Mortality is typically due to factors other than GI bleeding and occurs primarily in patients who are older and use medications such as nonsteroidal anti-inflammatory drugs (and, more recently, antiplatelet agents such as clopidogrel).

Among patients on long-term, low-dose aspirin, the risk of overt GI bleeding is increased twofold compared to placebo with an annual incidence of major GI bleeding of 0.13%. Compared with aspirin alone, the combination of aspirin and clopidogrel causes a two- to threefold increase in the number of patients with major GI bleeding. Definite risk factors for bleeding in patients taking aspirin and clopidogrel are a history of peptic ulcers and prior GI bleeding, and likely risk factors are male gender, age more than 70 years, and Helicobacter pylori infection. Mortality among patients with upper GI bleeding is often due to cardiovascular complications and comorbidities, and not due to uncontrollable GI hemorrhage. In most patients who develop GI bleeding while on aspirin, the aspirin therapy should be restarted once the risk for cardiovascular complications outweighs the risk for bleeding.

Chan FK, Ching JY, Hung LC, et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med. 2005;352:238–244.   [PubMed: 15659723]
McQuaid KR, Laine L. Systematic review and meta-analysis of adverse events of low-dose aspirin and clopidogrel in randomized controlled trials. Am J Med. 2006;119:624–638.   [PubMed: 16887404]

Symptoms and Signs

The clinical presentation of bleeding should be characterized. Hematemesis is overt bleeding with vomiting of fresh blood or clots. Melena refers to dark black and tarry-appearing stool, with a distinctive smell. The term "coffee grounds" describes gastric aspirates or vomitus that contains dark specks of old blood. Hematochezia is the passage of fresh blood or clots per rectum. Although bright red blood per rectum is usually indicative of a lower GI source, it ...

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