Upper gastrointestinal bleeding

Overview
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.

Clinical presentation
Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, maroon 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 physician 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
There are many causes for upper GI 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. 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.
 * Hematobilia, or bleeding from the biliary tree
 * Hemosuccus pancreaticus, or bleeding from the pancreatic duct

Summary
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.

Prevalence of upper GI bleeding
About 75% of patients presenting to the emergency room 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 room with GI bleeding have an upper source. Determining whether a patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult.

Diagnostic testing
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). 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.

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. Cuellar found the following results:

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. Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on all control samples.

A note on Bayesian calculations
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 such as those listed above under Prevalences.

Treatment
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
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.