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Introduction
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In the U.S., acute upper gastrointestinal bleeding (UGIB) is more common than lower gastrointestinal bleeding (LGIB). UGIB typically presents as hematemesis (vomiting of blood or coffee-ground appearing material), or melena (black, tarry stools). Mortality for inpatient UGIB is 9.7% and 30-day mortality is 10% (Roberts et al, 2020).
Causes
Major causes include gastric or duodenal ulcer, severe or erosive gastritis/duodenitis/esophagitis, esophagogastric varices, portal hypertensive gastropathy, angiodysplasia, arteriovenous malformation, esophageal (Mallory-Weiss) tear, and upper GI polyps/cancers. The source of bleeding cannot be determined in 10-15% of patients with UGIB.
Initial Evaluation
Rapid assessment and management of airway, breathing and circulation is the initial priority. Once the patient is stabilized, the goal is to assess the severity of the bleed, identify the potential source, and determine if there are conditions that may affect the management.
- History
- Previous episodes of upper GI bleeding
- Liver disease or alcohol abuse may cause varices or portal hypertensive gastropathy)
- Abdominal aortic aneurysm or aortic graft (may cause aorto-enteric fistula)
- Renal disease, aortic stenosis, or hereditary hemorrhagic telangiectasia (may cause angiodysplasia)
- Helicobacter pylori (H. pylori) infection or smoking (can lead to peptic ulcer disease)
- Smoking, alcohol abuse, or H. pylori infection (may increase risk of GI malignancy)
- Hospitalization for a life-threatening illness (may cause stress ulcers, especially in patients with respiratory failure)
- Vomiting, straining with stool or lifting, or severe coughing (may precipitate Mallory-Weiss tear)
- Comorbid conditions that may affect management include:
- Coronary artery disease and pulmonary disease make patients susceptible to adverse effects of anemia.
- Renal disease and heart failure predispose patients to volume overload with fluid resuscitation or blood transfusions.
- Coagulopathies, thrombocytopenia, or liver dysfunction may make bleeding difficult to control and may require transfusion of fresh frozen plasma (FFP) or platelets.
- Dementia or hepatic encephalopathy could cause aspiration of GI contents; endotracheal intubation may be considered in these patients.
- Medication History
- Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) (may cause peptic ulcers)
- Antiplatelet agents and anticoagulants (may contribute to GI bleeding)
- Serotonin reuptake inhibitors (SSRI), calcium channel blockers, and aldosterone antagonists (associated with GI bleeding)
- Bismuth and iron (can cause black stools)
- Patient symptoms such as dizziness, light-headedness, confusion, angina, severe palpitations, and cold/clammy extremities, upper abdominal pain, gastroesophageal reflux, dysphagia, nausea, emesis, jaundice, abdominal distension (ascites), involuntary weight loss, cachexia
- Physical Examination
- Tachycardia
- Orthostatic or supine changes in blood pressure (may suggest moderate to severe blood loss)
- Hypotension (suggests life-threatening blood loss)
- Rectal exam (to assess stool color [melena, hematochezia, brown])
- Significant abdominal tenderness with signs of involuntary guarding (suggests perforation)
- Signs of advanced liver disease such as jaundice, ascites, and altered mental status
- Laboratory Tests
- Type and crossmatch if patient is high-risk, hemodynamically unstable, or has severe bleeding
- Type and screen for hemodynamically stable patient without signs of severe bleeding
- Complete blood count
- Initial hemoglobin, then every 2 to 8 hours, depending on severity of the bleed
- Note excessive crystalloid administration can cause a falsely low hemoglobin value
- Serum electrolytes
- Liver enzymes (AST, ALT)
- Coagulation studies
- Ratio of blood urea nitrogen to serum creatinine greater than 30
- Serial electrocardiogram and cardiac enzymes may be indicated in patients at risk for demand ischemia or myocardial infarction
- Check stool for occult blood
- Nasogastric lavage may be helpful if source of bleeding is unclear or to clean stomach prior to endoscopy. If esophagogastric varices are suspected, place gastric tubes only at discretion of gastroenterologist.