A 72-year-old man presents to the emergency department for evaluation of dizziness, weakness, and black, tarry stools. He has a history of diabetes, coronary artery disease, and myocardial infarction 1 year ago that was treated with a drug-eluting stent. He takes both aspirin and clopidogrel.
- What additional questions would you ask to learn more about his symptoms?
- How do you approach gastrointestinal bleeding?
- Can you make a diagnosis with a good history?
Gastrointestinal (GI) bleeding is a common medical condition. Most patients with acute GI bleeding present to the emergency department or develop bleeding while hospitalized for another reason. The respective annual incidence of acute upper and lower GI bleeding is 100 to 200 and 20 to 27 cases per 100,000 population.1–7 Distinguishing between upper and lower GI bleeding is critical because the differential diagnosis and management vary. The prognosis ranges from trivial to life threatening.
Patients with acute GI bleeding require rapid evaluation and treatment. The initial history and physical examination provide information about the severity, duration, location, and possible etiology of GI bleeding. This initial assessment guides initial fluid resuscitation, triage within the hospital, timing of diagnostic procedures, and therapy.
|Hematemesis||Vomiting of bright red (fresh) blood or old "coffee-ground" material.|
|Hematochezia||Bright red blood, maroon blood, or clots per rectum.|
|Melena||Black, tarry, foul-smelling stools.|
|Upper gastrointestinal bleeding (UGIB)||Bleeding that originates proximal to the ligament of Treitz (ie, esophagus, stomach, or duodenum). Manifests in 3 ways: (1) hematemesis, (2) melena, or (3) hematochezia.|
|Lower gastrointestinal bleeding (LGIB)||Bleeding that originates distal to the ligament of Treitz (ie, small intestine [5%] or colon [95%]). Manifested by hematochezia.|
|Hemodynamic instability||Systolic blood pressure < 100 mm Hg and/or pulse > 100 beats per minute. Indicates significant intravascular volume loss.|
|Positive nasogastric aspirate||The presence of bright red blood, clots, or coffee-ground material aspirated from nasogastric tube; confirms UGIB. Red blood suggests active bleeding.|
UGIB originates from sources above the ligament of Treitz. Lack of hematemesis does not exclude UGIB because bleeding may be intermittent or arise from the distal duodenum. LGIB originates from sources beyond the ligament of Treitz. Melena usually indicates UGIB; however, bleeding from the small intestine or proximal colon with slow transit time may also cause melena. Hematochezia usually indicates LGIB, although 10% of episodes result from brisk UGIB.
Historically, approximately 50% of UGIB was attributed to peptic ulcer disease (PUD).8 However, in a recent analysis of the Clinical Outcomes Research Initiative (CORI) national database that includes community, academic, and Veterans Affairs endoscopy practices, the most common abnormality on an esophagogastroduodenoscopy for UGIB was "mucosal abnormality" (40%).9 PUD was the second most common diagnosis (21%), followed by esophageal inflammation (~15%), varices (11%), arteriovenous malformations (~5%), Mallory-Weiss tear (~3%), and tumors (~1%).9
Clinical characteristics help classify patients with UGIB ...