Chapter 155

1. What is the timing and treatment of peptic ulcer disease?

2. What are the factors in diagnosis and treatment of aortoenteric fistula?

3. What treatments are available for each etiology of upper GI bleeding?

4. What is the appropriate management and follow-up of variceal bleeding?

5. How do you estimate the severity of bleeding so that you can triage appropriate patients to the ICU, medical floor, or observation unit?

6. Which patients are more likely to rebleed and hence require continued observation in the hospital after their bleeding has apparently stopped, and for how long?

Upper gastrointestinal (GI) bleeding is responsible for over 300,000 hospitalizations per year in the United States. An additional 100,000 to 150,000 patients develop upper GI bleeding during hospitalizations. The annual cost of treating nonvariceal acute upper GI bleeding in the United States exceeds $2.5 billion. In 2004, for patients with and without complications of non-variceal upper GI bleeding in the United States, mean lengths of stay were 4.4 and 2.7 days, respectively, and hospitalization costs were$5632 and \$3402, respectively.

Upper GI bleeding is defined as a bleeding source in the GI tract proximal to the ligament of Treitz. The presentation varies depending on the nature and severity of bleeding and includes hematemesis, melena, hematochezia (in rapid upper GI bleeding), and anemia with heme-positive stools. Bleeding can be associated with changes in vital signs, including tachycardia and hypotension. Given the range of presentations, pinpointing the nature and severity of GI bleeding can be a challenging task.

The natural history of nonvariceal upper GI bleeding is that 80% of patients will stop bleeding spontaneously and no further urgent intervention will be needed. However if a patient rebleeds, there is a 10-fold increased mortality rate. In contrast, only 50% of patients with a variceal hemorrhage stop bleeding spontaneously. Following cessation of active variceal bleeding, there is a high risk of recurrent bleeding within six weeks.

The mortality rate for nonvariceal upper GI bleeding is 5% to 14%. This mortality rate is essentially unchanged since 1945, despite the development of new medications, endoscopy (both diagnostic and therapeutic), intensive care units, and advances in surgical management. The mortality remains high since patients with GI bleeding now are older, have more comorbidities, and are taking more medications including nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, and antiplatelet agents. For variceal bleeding, mortality is between 15% to 50% for each bleeding episode, and 70% to 80% in those with continuous bleeding. Variceal hemorrhage is responsible for one-third of all deaths due to cirrhosis.