Upper gastrointestinal bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper gastrointestinal bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the splenic flexure of the colon.

Upper gastrointestinal bleeds are considered medical emergencies, and require admission to hospital for urgent diagnosis and management. Due to advances in medications and endoscopy, upper gastrointestinal hemorrhage is now usually treated without surgery.

Clinical presentation

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Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, marroon stool, or hematochezia if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage.

Patients may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath.

The physical examination performed by the physcian concentrates on the following things:

• Vital signs, in order to determine the severity of bleeding and the timing of intervention
• Abdominal and rectal examination, in order to determine possible causes of hemorrhage
• Assessment for portal hypertension and stigmata of chronic liver disease in order to determine if the bleeding is from a variceal source.

Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.

Causes

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There are many causes for upper gastrointestinal hemorrhage. Causes are usually anatomically divided into their location in the upper gastrointestinal tract.

Patients are usually stratified into having either variceal or non-variceal sources of upper GI hemorrhage, as the two have different treatment algorithms and prognosis.

The causes for upper GI hemorrhage include the following:

• Esophageal causes:
  • Esophageal varices
  • Esophagitis
  • Esophageal cancer
  • Esophageal ulcers

• Gastric causes:
  • Gastric ulcer
  • Gastric cancer
  • Gastritis
  • Gastric varices
  • Gastric antral vascular ectasia, or watermelon stomach
  • Dieulafoy's lesions

• Duodenal causes:
  • Duodenal ulcer
  • Vascular malformations, including aorto-enteric fistulae
  • Hematobilia, or bleeding from the biliary tree

Treatment

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Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions, and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to be administered. Vitals signs are continuously monitored.

Early endoscopy is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the lesion identifies, and can include:

• injection of adrenaline or other sclerotherapy
• electrocautery
• endoscopic clipping
• or banding of varices

Stigmata of high risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding.

Pharmacotherapy includes the following:

• Proton pump inhibitors (PPIs), which reduce gastric acid production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage. These can be administered orally or intravenously as an infusion depending on the risk of rebleeding.
• Octreotide is a somatostatin analog believed to shunt blood away from the splanchnic circulation. It has found to be a useful adjunct in management of both variceal and non-variceal upper GI hemorrhage. It is the somatostatin analog most commonly used in North America.
• Terlipressin is a somatostatin analog most commonly used in Europe for variceal upper GI hemorrhage.
• Antibiotics are prescribed in upper GI bleeds associated with portal hypertension

If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested.

Refractory bleeding

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Refractory cases of upper GI hemorrhage may require:

• Repeat esophagogastroduodenoscopy
• Anti-fibrinolytics, such as tranexamic acid
• Angiography to identify and possibly occlude the feeder vessel
• Recombinant Factor VII is sometimes used as an adjunct in refractory bleeding, but its utility has only been tested for variceal hemorrhage
• Balloon tamponade
• Surgery, to oversew or remove the area of hemorrhage

Certain causes of upper GI hemorrhage (including gastric ulcers require repeat endoscopy after the episode of bleeding to ascertain healing of the causative lesion.

See also

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• Lower gastrointestinal bleeding

External links

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• eMedicine
• FP Notebook
• Patient.uk
• NIH/Medline

Gastroenterology | Medical emergencies

Obere Gastrointestinale Blutung