Upper gastrointestinal bleeding
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more. In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using the Gastroccult test.
The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood. A number of medications may improve outcomes depending on the source of the bleeding. Although proton pump inhibitors are often given in the emergent setting, there is no evidence that these medications decrease death rates, re-bleeding events, or needs for surgical interventions. After the initial resuscitation has been completed, treatment is instigated to limit the likelihood of rebleeds and correct any anaemia that the bleeding may have caused.
Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding. In people with a confirmed peptic ulcer, there is conflicting evidence if proton pump inhibitors reduce death rates, but PPIs do reduce the risk of re-bleeding and the need for surgery among this group. In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance. Tranexamic acid might be effective to reduce mortality, but the evidence for this is weak. But the evidence is promising. Somatostatin and octreotide while recommended for variceal bleeding have not been found to be of general use for non-variceal bleeds.
For initial fluid replacement colloids or albumin is preferred in people with cirrhosis. Medications typically includes octreotide or if not available vasopressin and nitroglycerin to reduce portal pressures. This is typically in addition to endoscopic banding or sclerotherapy for the varicies. If this is sufficient then beta blockers and nitrates may be used for the prevention of re-bleeding. If bleeding continues then balloon tamponade with a Sengstaken-Blakemore tube or Minnesota tube may be used in an attempt to mechanically compress the varicies. This may then be followed by a transjugular intrahepatic portosystemic shunt.
The benefits versus risks of placing a nasogastric tube in those with upper GI bleeding are not determined. Endoscopy within 24 hours is recommended. Prokinetic agents such as erythromycin before endocopy can decrease the amount of blood in the stomach and thus improve the operators view. Early endoscopy decreases hospital time and the amount of blood transfusions needed. Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found. It is also recommended that people with high risk signs are kept in hospital for at least 72 hours. Blood is not recommended to correct anaemia, unless the patient is cardiovascularly unstable as this can worsen outcomes. Oral iron can be used, but this can lead to problems with compliance, tolerance, darkening stools which may mask evidence of rebleeds and tends to be slow, especially if used in conjunction with PPIs. Parenteral Iron is increasingly used in these cases to improve patient outcomes and void blood usage.
About 75% of patients presenting to the emergency department with GI bleeding have an upper source . The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of patients in the emergency department with GI bleeding have an upper source.