1. ACUTE UPPER GI BLEEDING
ESSENTIALS OF DIAGNOSIS
Hematemesis (bright red blood or “coffee grounds”).
Melena in most cases; hematochezia in massive upper GI bleeds.
Volume status to determine severity of blood loss; hematocrit is a poor early indicator of blood loss.
Endoscopy diagnostic and may be therapeutic.
There are over 250,000 hospitalizations a year in the United States for acute upper GI bleeding. In the United States, the mortality rate for nonvariceal upper GI bleeding has declined steadily over the past 20 years to 2.1%. Mortality is higher in patients who are older than age 60 years and in patients in whom bleeding develops during hospitalization. Patients seldom die of exsanguination but rather of complications from an underlying disease.
The most common presentation of upper GI bleeding is hematemesis or melena. Hematemesis may be either bright red blood or brown “coffee grounds” material. Melena develops after as little as 50–100 mL of blood loss in the upper GI tract, whereas hematochezia requires a loss of more than 1000 mL. Although hematochezia generally suggests a lower bleeding source (eg, colonic), severe upper GI bleeding may present with hematochezia in 10% of cases.
Upper GI bleeding is self-limited in 80% of patients; urgent medical therapy and endoscopic evaluation are obligatory in the rest. Patients with bleeding more than 48 hours prior to presentation have a low risk of recurrent bleeding.
Peptic ulcers account for 40% of major upper GI bleeding with an overall mortality rate of less than 5%. In North America, the incidence of bleeding from ulcers is declining due to eradication of H pylori and prophylaxis with PPIs in high-risk patients.
Portal hypertension accounts for 10–20% of upper GI bleeding. Bleeding usually arises from esophageal varices and less commonly gastric or duodenal varices or portal hypertensive gastropathy. Approximately 25% of patients with cirrhosis have medium to large esophageal varices, of whom 30% experience acute variceal bleeding within a 2-year period. Due to improved care, the hospital mortality rate has declined over the past 20 years from 40% to 15%. Nevertheless, a mortality rate of 60–80% is expected at 1–4 years due to recurrent bleeding or other complications of chronic liver disease.
Lacerations of the gastroesophageal junction cause 5–10% of cases of upper GI bleeding. Many patients report a history of heavy alcohol use or retching. Less than 10% have continued or recurrent bleeding.
Vascular anomalies are found throughout the GI tract and may be the source of chronic or acute GI bleeding. They account for 7% of cases of acute upper tract bleeding. The most common are angioectasias (angiodysplasias) (eFigure 15–1), which are 1–10 mm distorted, aberrant submucosal vessels caused by chronic, intermittent obstruction of submucosal veins. They have a bright red stellate appearance and ...