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Upper gastrointestinal bleeding (UGIB) is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock.

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Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and rarer causes such as gastric cancer. The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine the hemoglobin.

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Significant upper gastrointestinal bleeding is considered a medical emergency. Fluid replacement, as well as blood transfusion, may be required. Endoscopy is recommended within 24 hours and bleeding can be stopped by various techniques. Proton pump inhibitors are often used. A 1995 UK study found an estimated mortality risk of 11% in those admitted to hospital for gastrointestinal bleeding.

There are many causes for upper gastrointestinal 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 gastrointestinal hemorrhage, as the two have different treatment algorithms and prognosis.

The causes for upper gastrointestinal hemorrhage include the following:

  • Esophageal causes (gastrorrhagia):
  • Esophageal varices
  • Esophagitis
  • Esophageal cancer
  • Esophageal ulcers
  • Mallory-Weiss tear
  • Gastric causes:
  • Gastric ulcer
  • Gastric cancer
  • Gastritis
  • Gastric varices
  • Gastric antral vascular ectasia
  • Dieulafoy's lesions
  • 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.
  • Hematobilia, or bleeding from the biliary tree
  • Hemosuccus pancreaticus, or bleeding from the pancreatic duct
  • Severe superior mesenteric artery syndrome

Diagnosis

right|thumb|[[Esophagogastroduodenoscopy|Endoscopic image of small gastric ulcer with visible blood vessels]]

Diagnostic testing

The strongest predictors of an upper gastrointestinal bleed are black stool, age <50 years, and blood urea nitrogen/creatinine ratio 30 or more.

Bayesian calculation

The predictive values cited are based on the prevalences of upper gastrointestinal bleeding in the corresponding studies. A clinical calculator can be used to generate predictive values for other prevalences.

Treatment

The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood. A number of medications may improve outcomes depending on the source of the bleeding. Proton pump inhibitors decrease gastric acid production.

Peptic ulcers

Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding. They may decrease signs of bleeding at endoscopy however. But the evidence is promising. Somatostatin and octreotide while recommended for variceal bleeding have not been found to be of general use for non-variceal bleeds. This is typically in addition to endoscopic banding or sclerotherapy for the varices. If the INR is greater than 1.5 to 1.8 correction with fresh frozen plasma, prothrombin complex may decrease mortality. The benefits versus risks of placing a nasogastric tube in those with upper gastrointestinal bleeding are not well known. However, survival has improved to about 2 percent, likely as a result of improvements in medical therapy and endoscopic control of bleeding.

Epidemiology

About 75% of people presenting to the emergency department with gastrointestinal bleeding have an upper source. The diagnosis is easier when the people have hematemesis. In the absence of hematemesis, 40% to 50% of people in the emergency department with gastrointestinal bleeding have an upper source.

See also

  • Lower gastrointestinal bleeding
  • Forrest classification
  • Rockall score

References

  • Patient.uk