Upper Gastrointestinal Hemorrhage

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Clinical-manifestations 5 Laboratory 6 Diagnostic-procedures 7 Radiology 8 Management 9 More General Terms 10 Additional Terms 11 References

More Specific Terms

• angiodysplasia (angiectasia)
• aortoenteric fistula
• comorbid conditions that increase mortality of upper GI bleed
• esophageal varices
• hemosuccus pancreaticus
• Mallory-Weiss tear
• melena
• peptic ulcer disease (PUD)
• stress ulceration

Introduction

• Upper gastrointestinal ( GI) hemorrhage refers to bleeding proximal to the jejunum (or ligament of Treitz). Mortality may be as high as 10%.

Etiology

• peptic ulcer: duodenal (21%), gastric (20%)
• erosive gastritis (13%), NSAID use
• esophageal varices (10%)
• angiodysplasia (gastric & duodenal) (7%)
• erosive esophagitis (6%)
• Mallory-Weiss tear (5%)
• pyloric channel ulcer (2%)
• gastric tumor (2%)
• erosive duodenitis
• Dieulafoy's lesion
• anastamotic ulcer
• aortoenteric fistula
• metastatic tumor to the duodenum
• gastric polyps
• hematobilia
• Menetrier's disease
• Schonlein-Henoch purpura
• Osler-Weber-Rendu syndrome
• stress ulceration
• idiopathic (13%)

Clinical-manifestations

• hematemesis
• coffee-ground emesis
• melena
• infrequently, bright-red-blood per rectum

Laboratory

• (see gastrointestinal hemorrhage)
• serum creatinine, serum urea nitrogen

• BUN/creatinine ratio of > 30 suggests upper GI bleed

• H. pylori serology or other H. pylori testing if biopsy negative for H pylori

Diagnostic-procedures

• esophagogastroduodenoscopy ( EGD)

• within 24 hours [5]
• routine 2nd look not recommended [5]
• endoscopic coagulation or injection for

• actively bleeding ulcers
• visble vessels
• sentinal clots

• endoscopic ligation or sclerosis of esophageal varices
• mechanical ( clips) vs thermal hemostasis with similar outcomes [6]
• biopsy for Helicobacter pylori

• arteriography

• failure of EGD to visualize source of bleeding
• bleeding of > 0.5 mL/min at the time of study
• arterial angiotherapy

• vasopressin 0.15-2.0 units/min in selectively catheterized bleeding artery
• arterial embolization

• selective arterial catheterization
• absorbable gelatin powder (Gelfoam)

Radiology

• upper GI with barium has no role in initial evaluation of active upper GI bleed

Management

• general recommendations: [9]

• use prognostic scales to assess risk for rebleeding & death
• transfuse patients with hemoglobin <7 mg/dL
• do not delay endoscopy to correct coagulopathies or to administer proton-pump inhibitor ( PPI) therapy to downsize lesions
• discharge low-risk patients soon after endoscopy
• perform endoscopy early (within 24 hours) for most patients
• bolus- & continuous- infusion PPI for high-risk patients after successful endoscopy
• hospitalize high-risk patients at least 72 hours
• prescribe daily proton pump inhibitor at discharge
• if endoscopic treatment fails, percutaneous embolization can be considered as an alternative to surgery
• in patients with peptic ulcers, test for, treat, & eradicate Helicobacter pylori [5,9]
• nonspecific NSAIDs plus a proton pump inhibitor or a COX2 inhibitor alone associated with bleeding risk; COX-2 inhibitor plus a PPI recommended if NSAID required
• restart low-dose aspirin for cardiovascular prophylaxis as soon as benefit outweighs bleeding risk; clopidogrel confers higher risk aspirin plus a proton pump inhibitor [9]

• general measures (see gastrointestinal hemorrhage)

• insert nasogastric tube for aspiration to confirm diagnosis
• also see algorithm for management of GI bleed

• Minnesota Esophagogastric Tamponade Tube for acute bleeding refractory to other measures (see esophageal varices)
• esophagogastroduodenoscopy ( EGD) see above

• IV bolus of proton pump inhibitor before endoscopy, followed by infusion after EGD [2, 5]
• octreotide 50 ug IV bolus, then 25-50 ug/hour IV drip (superior to vasopressin)

• for use in conjunction with EGD
• octreotide alone does not improve outcome of non- esophageal varices upper GI bleed [3]

• H2-receptor antagonists are NOT effective in stopping active UGI bleed

• therapy for specific lesions

• peptic ulcer:

• continue proton pump inhibitor only if peptic ulcer is the source of bleeding [3]

• esophageal varices
• Mallory-Weiss tear
• aortoenteric fistula
• angiodysplasia

• empiric prophylactic therapy with broad-spectrum antibiotics is indicated in patients with cirrhosis [3]
• prognosis

• patients taking NSAIDs at the time of hemorrhage

• switching to COX-2 inhibitor or adding omeprazole to NSAID results in similar rebleed rate = 5% [4]

• prophylaxis

• proton pump inhibitor reduces risk of GI bleed associated with anti-platelet agent [7]

More General Terms

• gastrointestinal hemorrhage

Additional Terms

• melena
• Minnesota esophagogastric tamponade tube
• octreotide (Sandostatin)
• upper gastrointestinal (GI) endoscopy (esophagogastroduodenoscopy, EGD)

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 300-302
2. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 346-353
3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006
4. Journal Watch 23(3):25-26, 2003 Chan FKL et al, N Engl J Med 347:2104, 2002 PMID: &dopt=Abstract
5. Journal Watch 24(2):20, 2004 Barkun A, Bardou M, Marshall JK; Nonvariceal Upper GI Bleeding Consensus Conference Group. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2003 Nov 18;139(10):843-57. PMID: [1]
6. Saltzman JR, Strate LL, Di Sena V, Huang C, Merrifield B, Ookubo R, Carr-Locke DL. Prospective trial of endoscopic clips versus combination therapy in upper GI bleeding (PROTECCT--UGI bleeding). Am J Gastroenterol. 2005 Jul;100(7):1503-8. PMID: [2] (appears that guideline associated with this reference has been withdrawn in Dec 2009)
7. Ibanez L, Vidal X, Vendrell L, Moretti U, Laporte JR; Spanish- Italian Collaborative Group for the Epidemiology of Gastrointestinal Bleeding. Upper gastrointestinal bleeding associated with antiplatelet drugs. Aliment Pharmacol Ther. 2006 Jan 15;23(2):235-42. PMID: [3]
8. Barkun AN et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010 Jan 19; 152:101. PMID: [4]
9. National Guideline Clearinghouse
   - ASGE guideline: the role of endoscopy in acute non-variceal upper-GI hemorrhage. American Society for Gastrointestinal Endoscopy ngc-guideline: [5]
   - ACR Appropriateness Criteria Radiologic management of lower gastrointestinal tract bleeding. American College of Radiology ngc-guideline: [6]
   - Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. Scottish Intercollegiate Guidelines Network (SIGN). ngc-guideline: [7]
   - Upper gastrointestinal bleeding, American College of Radiology ngc-guideline: [8]

upper gastrointestinal hemorrhage