51 UPPER GASTROINTESTINAL BLEEDING
G. Edward Kimm Jr. M.D., Allen T. Belshaw M.D.

1. What is upper gastrointestinal (GI) bleeding?

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Bleeding from proximal to the ligament of Treitz (the transition point between duodenum and jejunum).

2. What are the most common causes of upper GI bleeding?

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In descending order of frequency, they are gastritis, duodenal ulcer, esophageal varices, benign gastric ulcer, esophagitis, and Mallory-Weiss tear. All other causes account for < 5% of cases.

3. What is the overall mortality rate of upper GI bleeding?

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Approximately 10%. Mortality is usually associated with comorbid factors such as cardiac, pulmonary, hepatic, and renal disease as well as age (> 60 years) and large transfusion requirements (> 5 units of blood). Patients who rebleed during the same hospitalization have a mortality rate of 30%.

4. What is the most common presentation of upper GI bleeding?

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Eighty percent of patients present with melena (blood is a cathartic, and patients pass black, tarry, or maroon-colored stools) or hematochezia (bright red blood in the rectum). Hematemesis (bright red or coffee-ground emesis) is diagnostic of an upper source of GI bleeding. Occult bleeding may present only with guaiac-positive stool.

5. How much GI blood loss is necessary to cause melena?

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As little as 50 mL. Occult bleeding (guaiac- or Hematest-positive) can be detected with as little as 10 mL of blood loss.

6. A 45-year-old man presents to the emergency department with massive hematemesis, tachycardia, and hypotension. What should the initial approach be?

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Acute GI hemorrhage requires a prompt and systematic approach. As in all critically ill patients, initially assess the ABCs (airway, breathing, circulation). Start two large-bore intravenous (IV) lines, and give 1 L of Ringer’s lactate while monitoring the patient. Place a nasogastric tube (NGT) and Foley catheter and irrigate the NGT with saline. Send blood for type and crossmatch and coagulation and liver function tests.

7. This patient stabilizes after your interventions. Is a medical history of any value in determining a cause of the bleeding?

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Yes. The following are pertinent:

* Previous symptoms of peptic ulcer disease or nonsteroidal anti-inflammatory drug use: bleeding duodenal or gastric ulcer
* History of gastroesophageal reflux disease: esophagitis
* Heavy alcohol use: gastritis or bleeding varices
* Recent retching or vomiting: Mallory-Weiss tear
* Weight loss: upper GI malignancy

8. What physical finding may be helpful in establishing the source of bleeding?

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Physical examination is generally not helpful. The stigmata of liver disease (jaundice, caput medusa, ascites, muscle wasting) raise the suspicion of variceal bleeding or multiple superficial gastric erosions.

9. What percentage of patients with known esophageal varices are bleeding from the varices on presentation?

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Only 50%.

10. Does bilious or clear NGT aspirate rule out an upper GI source of hemorrhage?

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No. Although NGT aspiration can be useful in directing the search for a bleeding site, one should keep in mind that the false-negative rate may be as high as 20%.

11. What studies can be used to determine the source of bleeding?

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Esophagogastroduodenoscopy (EGD) is the first and best test. Barium studies may miss a significant source of upper GI bleeding, such as erosive gastritis, and interfere with other more definitive tests, especially arteriography. Nuclear scans are of limited value in acute upper GI hemorrhage.

12. What is the sensitivity of EGD?

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EGD identifies the source of bleeding in up to 95% of cases. EGD has the advantage of directly visualizing the source of blood loss and provides the opportunity to biopsy a lesion and perform therapeutic maneuvers such as cauterizing a bleeder in a duodenal ulcer.
KEY POINTS: UPPER GI BLEEDING

1. Upper GI bleeding is defined as bleeding proximal to the ligament of Treitz.
2. The most common causes are gastritis, duodenal ulcer, esophageal varices, benign gastric ulcer, esophagitis, and Mallory-Weiss tear.
3. Eight percent of patients present with melena or hematochezia.
4. EGD identifies the source of bleeding in 95% of cases.

13. How can EGD be used to control nonvariceal bleeding?

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Electrocautery and injection of vasoconstrictors are well-established techniques. Other modalities such as argon beam coagulation, hemoclips, and cyanoacrylates (super glue) are promising.

14. What amount of bleeding is required to see a “blush” on arteriography?

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Less than 5 mL per minute. Although angiography is the most invasive of these tests, the catheter can be left in place and used for delivery of therapeutic vasopressin or embolization.

15. What treatment options are available to control variceal bleeding?

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Upper endoscopy with sclerotherapy or band ligation. In experienced hands, placement of a Sengstaken-Blakemore tube (a double balloon tube that permits direct tamponade of both gastric and esophageal varices) temporarily controls bleeding in 90% of cases. IV infusion of vasopressin or octreotide should decrease blood flow to the varices but is less successful in patients with more severe liver disease.

16. What are the indications for surgery in patients with upper GI hemorrhage?

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About 10% of patients eventually require surgery. Indications include:

* Persistent hypotension or shock (failure of resuscitative therapy)
* Recurrent bleeding while on maximal medical therapy
* High-risk patients with significant comorbid disease
* Large transfusion requirements (transfusion of more than two thirds of the patient’s blood volume in 24 hours)

17. What is the surgical approach to an unstable patient with a nonlocalized upper GI bleed who does not respond to initial resuscitation?

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At laporotomy start with a generous gastroduodenotomy centered over the pylorus. If this does not reveal a source of bleeding, proceed with a proximal gastrotomy.

18. A patient presents with hematemesis and has a remote history of an abdominal aortic aneurysm repair. What uncommon cause of upper GI bleeding needs to be considered?

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Aortoduodenal fistula. Any patient with a history of aortic surgery and evidence of GI bleeding should be aggressively worked up for aortoenteric fistula. The study of choice is endoscopy.

19. What is a Dieulafoy’s ulcer?

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A gastric vascular malformation with an exposed submucosal artery, usually within 2-5 cm of the gastroesophageal junction. It presents with painless hematemesis, often massive (fortunately, this is uncommon).

20. A patient recently admitted with a traumatic liver laceration is treated nonoperatively and later develops painless hematemesis. What do you suspect? How should you treat this patient?

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Hemobilia, another rare cause of upper GI bleeding, usually occurs after liver trauma or hepatic resection. Treatment consists of angiographic embolization.

21. What are other rare causes of upper GI bleeding?

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Watermelon stomach, portal hypertensive gastropathy, arteriovenous malformations, upper GI neoplasm, duodenal diverticulum, and pancreatitis (resulting in erosion into the splenic artery or splenic vein thrombosis with portal hypertension).

References
BIBLIOGRAPHY
1. Cameron JL: Current Surgical Therapy, 7th ed. St. Louis, Mosby, 2001.
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4. Jamieson GG: Current status of indications for surgery in peptic ulcer disease. World J Surg 24:256, 2000. Medline Similar articles
5. Savides TJ, Jensen DM: Therapeutic endoscopy for nonvariceal gastrointestinal bleeding. Gastroenterol Clin North Am 29:465-487, 2000. Medline Similar articles