Upper gastrointestinal bleeding
|Upper gastrointestinal bleeding|
|Classification and external resources|
Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper GI hemorrhage.
Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon.
Upper GI bleeds are considered medical emergencies, and require admission to hospital for urgent diagnosis and management. Due to advances in medications and endoscopy, upper GI hemorrhage is now usually treated without surgery.
Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, or hematochezia (maroon coloured stool) if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage.
- 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.
There are many causes for upper GI hemorrhage. Causes are usually anatomically divided into their location in the upper gastrointestinal tract.
People 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:
- Gastric causes:
- Duodenal causes:
- Duodenal ulcer
- Vascular malformation, including aorto-enteric fistulae. Fistulae are usually secondary to prior vascular surgery and usually occur at the proximal anastomosis at the third or fourth portion of the duodenum where it is retroperitoneal and near the aorta.234
- Hematobilia, or bleeding from the biliary tree
- Hemosuccus pancreaticus, or bleeding from the pancreatic duct
- Severe superior mesenteric artery syndrome
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.
Whiting studied a cohort of 325 patients and found the odds ratios for the strongest predictors were: black stool, 16.6 (95% confidence interval [CI], 7.7–35.7); age < 50 years, 8.4 (95% CI, 3.2–22.1); and blood urea nitrogen/creatinine ratio 30 or more, 10.0 (95% CI, 4.0–25.6).5 Seven (5%) of 151 with none of these factors had an upper GI tract bleed, versus 63 (93%) of 68 with 2 or 3 factors. Ernst found similar results.6
The nasogastric aspirate can help determine the location of bleeding and thus direct initial diagnostic and treatment plans. Witting found that nasogastric aspirate has sensitivity 42%, specificity 91%, negative predictive value 64%, positive predictive value 92% and overall accuracy of 66% in differentiating upper GI bleeding from bleeding distal to the ligament of Treitz. Thus, in this study a positive aspirate is more helpful than a negative aspirate. In a smaller study, Cuellar found a sensitivity of 79% and specificity of 55%, somewhat opposite results from Witting. Cuellar also studied the appearance of the aspirate and a summary of these results is available at the Evidence-Based On-Call database. Although the website lists these results as expired, they were available as of Oct, 16, 2006. These results are also available through the Wayback Archive and readers may consult the Archive if the original page is removed.
Determining whether blood is in gastric contents, either vomited or aspirated specimens, is surprisingly difficult. Slide tests are based on orthotolidine (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). Rosenthal found orthotolidine-based tests more sensitive than specific; the Hemoccult test's sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate 7 . Cuellar found the following results:
|Finding||Sensitivity||Specificity||Positive predictive value
(prevalence of 39%)
|Negative predictive value
(prevalence of 39%)
Holman used simulated gastric specimens and found the Hemoccult test to have significant problems with non-specificy and false-positive results, whereas the Gastroccult test was very accurate .9 Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on all control samples.
In a study published regarding a new scoring system called the Glasgow-Blatchford bleeding score in Lancet on January 3, 2009, 16% of patients presenting with upper GI bleed had GBS score of "0", considered low. Among these patients there were no deaths or interventions needed and the patients were able to be effectively treated in an outpatient setting. 10 11
Score is equal to "0" if the following are all present:
- Hemoglobin level >12.9 g/dL (men) or >11.9 g/dL (women)
- Systolic blood pressure >109 mm Hg
- Pulse <100/minute
- Blood urea nitrogen level <18.2 mg/dL
- No melena or syncope
- No past or present liver disease or heart failure
The predictive values cited are based on the prevalences of upper GI bleeding in the corresponding studies. A clinical calculator can be used to generate predictive values for other prevalences.
The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood.12 A number of medications may improve outcomes depending on the source of the bleeding.12 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.12 Proton pump inhibitors may reduce mortality in those with severe disease as well as the risk of re-bleeding and the need for surgery among this group.13 In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance.14 The evidence for the inhibition of fibrinolysis with tranexamic acid is insufficient to recommend it use.1215 But the evidence is promising.16 Somatostatin and octreotide while recommended for varicial bleeding have not been found to be of general use for non varicial bleeds.12
For initial fluid replacement colloids or albumin is preferred in people with cirrhosis.12 Medications typically includes octreotide or if not available vasopression and nitroglycerin to reduce portal pressures.17 This is typically in addition to endoscopic banding or sclerotherapy for the varicies.17 If this is sufficient then beta blockers and nitrates may be used for the prevention of re-bleeding.17 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.17 This may then be followed by a transjugular intrahepatic portosystemic shunt.17
If large amounts of pack red blood cells are used additional platelets and fresh frozen plasma should be administered to prevent coagulopathies.12 Some evidence supports holding off on blood transfusions in those who have a hemoglobin greater than 7 to 8 g/dL and only moderate bleeding.1218 If the INR is greater than 1.5 to 1.8 correction with fresh frozen plasma, prothrombin complex may decrease mortality.12
The benefits verses risks of placing a nasogastric tube in those with upper GI bleeding are not determined.12 Endoscopy within 24 hours is recommended.12 Prokinetic agents such as erythromycin before endocopy can decrease the amount of blood in the stomach and thus improve the operators view.12 Early endoscopy decreases hospital time and the amount of blood transfusions needed.12 Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found.12 It is also recommended that people with high risk signs are kept in hospital for at least 72 hours.12 Blood is not recommended to correct anaemia, unless the patient is cardiovascularly unstable as this can worsen outcomes.18 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 room with GI bleeding have an upper source .6 The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of patients in the emergency room with GI bleeding have an upper source 5 8 19
- "Are SSRIs associated with upper gastrointestinal bleeding in adults?". Global Family Doctor.
- Graber CJ et al. (2007). "A Stitch in Time — A 64-year-old man with a history of coronary artery disease and peripheral vascular disease was admitted to the hospital with a several-month history of fevers, chills, and fatigue". New Engl J Med 357 (10): 1029–34. doi:10.1056/NEJMcps062601. PMID 17804848.
- Sierra J, Kalangos A, Faidutti B, Christenson JT (2003). "Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy". Cardiovascular surgery (London, England) 11 (3): 185–8. doi:10.1016/S0967-2109(03)00004-8. PMID 12704326.
- Cendan JC, Thomas JB, Seeger JM (2004). "Twenty-one cases of aortoenteric fistula: lessons for the general surgeon". The American surgeon 70 (7): 583–7; discussion 587. PMID 15279179.
- Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M (2006). "ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis". Am J Emerg Med 24 (3): 280–5. doi:10.1016/j.ajem.2005.11.005. PMID 16635697.
- Ernst AA, Haynes ML, Nick TG, Weiss SJ (1999). "Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding". Am J Emerg Med 17 (1): 70–2. doi:10.1016/S0735-6757(99)90021-9. PMID 9928705.
- Rosenthal P, Thompson J, Singh M (1984). "Detection of occult blood in gastric juice". J. Clin. Gastroenterol. 6 (2): 119–21. doi:10.1097/00004836-198404000-00004. PMID 6715849.
- Cuellar RE, Gavaler JS, Alexander JA et al. (1990). "Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate". Arch. Intern. Med. 150 (7): 1381–4. doi:10.1001/archinte.150.7.1381. PMID 2196022.
- Holman JS, Shwed JA (1992). "Influence of sucralfate on the detection of occult blood in simulated gastric fluid by two screening tests". Clin Pharm 11 (7): 625–7. PMID 1617913.
- Stanley AJ, Ashley D, Dalton HR, et al. (January 2009). "Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation". Lancet 373 (9657): 42–7. doi:10.1016/S0140-6736(08)61769-9. PMID 19091393. Risk Stratification and Outpatient Care for Upper GI Bleeding Lay summary].
- "Glasgow-Blatchford bleeding score". Retrieved 2009-01-24.
- Jairath, V; Barkun, AN (2011 Oct). "The overall approach to the management of upper gastrointestinal bleeding.". Gastrointestinal endoscopy clinics of North America 21 (4): 657–70. doi:10.1016/j.giec.2011.07.001. PMID 21944416.
- Leontiadis, GI; Sreedharan, A, Dorward, S, Barton, P, Delaney, B, Howden, CW, Orhewere, M, Gisbert, J, Sharma, VK, Rostom, A, Moayyedi, P, Forman, D (2007 Dec). "Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding.". Health technology assessment (Winchester, England) 11 (51): iii–iv, 1–164. PMID 18021578.
- Sreedharan, A; Martin, J, Leontiadis, GI, Dorward, S, Howden, CW, Forman, D, Moayyedi, P (2010-07-07). "Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding". In Sreedharan, Aravamuthan. Cochrane database of systematic reviews (Online) (7): CD005415. doi:10.1002/14651858.CD005415.pub3. PMID 20614440.
- Gluud, LL; Klingenberg, SL, Langholz, E (2012-01-18). "Tranexamic acid for upper gastrointestinal bleeding". In Gluud, Lise Lotte. Cochrane database of systematic reviews (Online) 1: CD006640. doi:10.1002/14651858.CD006640.pub2. PMID 22258969.
- Gluud, LL; Klingenberg, SL, Langholz, SE (2008 May). "Systematic review: tranexamic acid for upper gastrointestinal bleeding". Alimentary pharmacology & therapeutics 27 (9): 752–8. doi:10.1111/j.1365-2036.2008.03638.x. PMID 18248659.
- Cat, TB; Liu-DeRyke, X (2010 Sep). "Medical management of variceal hemorrhage". Critical care nursing clinics of North America 22 (3): 381–93. doi:10.1016/j.ccell.2010.02.004. PMID 20691388.
- Villanueva, Càndid; Colomo, Alan; Bosch, Alba; Concepción, Mar; Hernandez-Gea, Virginia; Aracil, Carles; Graupera, Isabel; Poca, María et al. (2013). "Transfusion Strategies for Acute Upper Gastrointestinal Bleeding". New England Journal of Medicine 368 (1): 11–21. doi:10.1056/NEJMoa1211801. PMID 23281973.
- Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M (2004). "Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis". Ann Emerg Med 43 (4): 525–32. doi:10.1016/j.annemergmed.2003.09.002. PMID 15039700.