Upper gastrointestinal bleeding: Wikis

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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.
ICD-10 K92.2
ICD-9 578.9
eMedicine med/3565

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.

Contents

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:

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.

Gastric ulcer in antrum of stomach with overlying clot. Pathology was consistent with gastric lymphoma. Reproduced with permission of patient

The causes for upper GI hemorrhage include the following:

Diagnosis

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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.

Details

Prevalence of upper GI bleeding

About 75% of patients presenting to the emergency room with GI bleeding have an upper source [4]. 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] [6] [7] . 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)[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[4].

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[2]. 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%[3], 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 [8] . Cuellar found the following results:

Determining whether blood is in the gastric aspirate[7]
Finding Sensitivity Specificity Positive predictive value
(prevalence of 39%)
Negative predictive value
(prevalence of 39%)
Gastroccult 95% 82% 77% 96%
Physician assessment 79% 55% 53% 20%

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] [12]

Score is equal to "0" if the following are all present:

  1. Hemoglobin level >12.9 g/dL (men) or >11.9 g/dL (women)
  2. Systolic blood pressure >109 mm Hg
  3. Pulse <100/minute
  4. Blood urea nitrogen level <18.2 mg/dL
  5. No melena or syncope
  6. No past or present liver disease or heart failure

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

Endoscopic image of small gastric ulcer with visible vessel

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:

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.

Same ulcer seen after endoscopic clipping

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 vasopressin 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:

Certain causes of upper GI hemorrhage (including gastric ulcers require repeat endoscopy after the episode of bleeding to ascertain healing of the causative lesion.

See also

References

  1. ^ 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: 1029–34. doi:10.1056/NEJMcps062601. PMID 17804848. http://content.nejm.org/cgi/content/full/357/10/1029.  
  2. ^ 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.  
  3. ^ 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.  
  4. ^ a b 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. http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(99)90021-9.  
  5. ^ a b 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. http://linkinghub.elsevier.com/retrieve/pii/S0735-6757(05)00427-4.  
  6. ^ 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. http://linkinghub.elsevier.com/retrieve/pii/S0196064403009417.  
  7. ^ a b 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.  
  8. ^ 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.  
  9. ^ 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.  
  10. ^ "Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation". http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61769-9/abstract#. Retrieved 2009-01-24.  
  11. ^ [1]Stanley AJ et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: Multicentre validation and prospective evaluation. Lancet 2009 Jan 3; 373:42. Summary Retrieved from Journal Watch 1/20/09 from Journal Watch Gastroenterology January 9, 2009
  12. ^ "Glasgow-Blatchford bleeding score". http://www.ganfyd.org/index.php?title=Glasgow-Blatchford_score. Retrieved 2009-01-24.  

External links


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