Upper Gastrointestinal Bleeding

Aka: Upper Gastrointestinal Bleeding, Upper GI Bleed

1. See Also
   1. Gastrointestinal Bleeding Management
   2. Esophageal Varices
2. Epidemiology
   1. Accounts for 400,000 hospitalizations in U.S. yearly
3. Risk factors
   1. Helicobacter Pylori infection (present in 64% of cases)
      1. Upper Gastrointestinal Bleeding odds ratio: 1.7
      2. Adheres to gastric epithelium, predisposing underlying mucosa to injury by toxins
   2. Aspirin or NSAID use (most common cause)
      1. See NSAID Gastrointestinal Adverse Effects for relative risk of specific NSAIDs
      2. Upper Gastrointestinal Bleeding odds ratio: 4.8
      3. Upper Gastrointestinal Bleeding odds ratio: 6.1 if Helicobacter Pylori positive in addition to NSAID use
   3. Elderly (especially over age 70 years)
   4. Male gender (twice as common as women)
   5. Acid suppression therapy does not reduce bleeding risk
4. Causes: Adults
   1. Adults with acute massive GI Bleeding
      1. Peptic Ulcer Disease (62%)
         1. Gastric Ulcer (up to 55%)
         2. Duodenal Ulcer (30-38%)
      2. Esophageal Varices (6-10%)
      3. Gastritis or Duodenitis (5-10%)
      4. Esophagitis or esophageal ulcer (5-10%)
      5. Mallory-Weiss tear (3-7%)
      6. Gastrointestinal malignancy (1-4%)
      7. Arteriovenous malformation (10%)
      8. Dieulafoy's Lesion (1%)
         1. Artery at gastric fundus may bleed heavily
         2. Difficult to identify on endoscopy
      9. Gastric antral vascular ectasia (0.5 to 2%)
         1. Longitudinal erythematous stripes on gastric mucosa
         2. Known as Watermelon Stomach
      10. Conditions associated with angiodysplasia of Stomach or duodenum
          1. Chronic Renal Failure
          2. Aortic Stenosis
          3. Cirrhosis
          4. Von Willebrand's Disease
   2. Chronic intermittent GI Bleeding
      1. Gastritis (18 to 35%)
      2. Esophagitis (18 to 35%)
      3. Gastric Ulcer (18 to 21%)
      4. Duodenal Ulcer (3 to 15%)
      5. Angiodysplasia (5 to 23%)
      6. Gastric Cancer
   3. Most commonly missed upper GI sources
      1. Large Hiatal HerniaErosions
      2. Arteriovenous malformation
      3. Peptic Ulcer Disease
5. Causes: Children
   1. Esophagitis
   2. Gastritis
   3. Peptic Ulcer Disease
   4. Esophageal Varices
   5. Mallory-Weiss Tear
6. History
   1. History: Gastrointestinal
      1. Peptic Ulcer Disease
      2. Prior Gastrointestinal Bleeding
      3. Prior abdominal surgery
      4. Chronic Liver Disease
         1. Cirrhosis
         2. Chronic Hepatitis
         3. Esophageal Varices
   2. History: Comorbidity
      1. Coronary Artery Disease
      2. Diabetes Mellitus
      3. Chronic Kidney Disease
      4. Chronic Obstructive Pulmonary Disease
   3. Habits
      1. Tobacco abuse
      2. Alcohol Abuse
   4. Medications
      1. See Drug Induced Platelet Dysfunction
      2. Clopidogrel (Plavix)
      3. Warfarin (Coumadin)
      4. NSAIDs
      5. Aspirin
      6. Corticosteroids
      7. Selective Serotonin Reuptake Inhibitors (SSRI)
         1. Inhibit platelet aggregation
7. Symptoms
   1. Abdominal Pain
   2. Hematemesis
   3. Coffee-ground Emesis
   4. Black tarry stools or Melena
   5. Bright red blood per rectum or Hematochezia (if bleeding is brisk)
8. Signs
   1. Vital signs
      1. Do not be reassured by normal vital signs
         1. In contrast, abnormal vital signs mandate emergent management
      2. Tachycardia
         1. Initially normal
      3. Hypotension or Orthostasis
         1. Late finding, requires 20% loss of blood volume
   2. Abdominal exam
      1. Hyperactive Bowel Sounds
   3. Nasogastric aspirate bloody
      1. False negative rate is at least 15% and likely higher
      2. Fresh blood suggests persistant bleeding and suggests a high risk lesion
      3. Lavage offers higher sensitivity but increases risk of aspiration and is controversial
      4. Lavage positive for coffee ground material or bright red blood confirms upper gastrointestinal source
         1. However a negative lavage does not exclude Upper Gastrointestinal Bleeding
      5. Gastric Lavage may also help clear the Stomach of blood prior to endoscopy and improve the evaluation
9. Labs
   1. Complete Blood Count
      1. Baseline Hemoglobin (trails bleeding by 24 hours)
   2. Blood Type and Cross-match
   3. Coagulation Factors
      1. Prothrombin Time
      2. Platelet Count
   4. Liver Function Tests
   5. Renal Functions tests
      1. Blood Urea Nitrogen (BUN)
      2. Serum Creatinine
      3. BUN to Creatinine ratio
         1. Does not reliably distinguish upper GI source
10. Evaluation
    1. See Upper GI Bleeding Score
    2. See Rockall Risk Score
    3. See Upper Endoscopy Evaluation of GI Bleeding
11. Management: Acid reduction
    1. Proton Pump Inhibitor (preferred)
       1. Start Intravenous Proton Pump Inhibitor in all Upper Gastrointestinal Bleeding cases
          1. Better outcomes with use, although mixed results (see below)
       2. Effects
          1. Full protection (achlorhydria) is delayed for the 5-7 days required to deactivate the proton pump
             1. Consider H2 Blocker initially (see below)
          2. Not proven in-vivo to aid clotting
          3. No proven benefit in mortality and other outcomes
          4. Mixed results on overall Incidence of re-bleeding
          5. Omeprazole may heal ulcer if near-achlorhydria
       3. References
          1. Daneshmend (1992) BMJ 304:143-47
          2. Sreedharan (2010) Cochrane Database Syst Rev (2): CD005415
          3. Sung (2009) Ann Intern Med 150(7): 455-64
    2. H2 Blocker
       1. Use is controversial in Acute Gastrointestinal Hemorrhage
       2. Consider starting initially concurrently with Proton Pump Inhibitor to bridge the delay in full PPI activity
       3. Ranitidine
          1. Intermittent: 50 mg IV or IM every 6-8 hours
          2. Continuous: 6.25 mg/hour IV
12. Management: Stabilization of the actively bleeding patient
    1. General measures
       1. See Acute Gastrointestinal Bleeding Management
       2. ABC Management
       3. Supportive care (Oxygen, large bore IVs, fluid Resuscitation, consider intubation)
       4. Intensive Care Unit admission for significant bleeding or hemodynamically unstable
       5. Replace blood and Coagulation Factors if needed (e.g. pRBC, Fresh Frozen Plasma, Platelet Transfusion, Vitamin K)
          1. See Gastrointestinal Bleeding Management for indications
       6. Upper endoscopy urgently to emergently
          1. See Upper Endoscopy Evaluation of GI Bleeding
          2. See protocols below
    2. Esophageal Varices
       1. See Bleeding Esophageal Varices
       2. Upper Endoscopy emergently for banding
       3. Vasoactive agents (e.g. Octreotide)
       4. Non-selective Beta Blocker (e.g. Propranolol, Nadalol, Timolol)
       5. Prophylactic Antibiotics (e.g. Norfloxacin, Ciprofloxacin, Ceftriaxone)
       6. Consider Balloon tamponade
13. Management: Very low risk patients
    1. Indications
       1. Hemodynamically stable with normal lab testing
       2. No evidence of significant bleeding in last 48 hours
       3. Nasogastric Tube aspirate without blood
    2. Protocol
       1. Home with follow-up within days
       2. General measures as above
14. Management: Low risk patients
    1. Indications
       1. Hemodynamically stable within 1 hour of Resuscitation
       2. Minimal Blood Products required (2 PRBC or less)
       3. No evidence of active bleeding
       4. Nasogastric Tube aspirate without blood
       5. No active comorbid medical conditions
    2. Protocol
       1. Consider for rapid protocol
          1. Immediate Upper Endoscopy Evaluation of GI Bleeding
          2. Discharge to home if low-risk endoscopy results
       2. Admit if rapid protocol not available
          1. Follow moderate risk patient protocol below
       3. General measures as above
15. Management: Moderate risk patients
    1. Indications
       1. Tachycardia persists despite Resuscitation
       2. Blood Products required >2 PRBC
       3. Active comorbid condition
    2. Protocol
       1. General measures as above
       2. Admit to regular medical bed
       3. Upper endoscopy when patient stabilized (<24 hours)
          1. See Upper Endoscopy Evaluation of GI Bleeding
          2. Disposition based on Upper Endoscopy results
             1. Low risk endoscopy: Observe for 24 hours
             2. Moderate risk endoscopy: Observe for 48-72 hours
             3. High risk endoscopy
                1. Initially observe in ICU for at least 24 hours
                2. Observe in hospital for 72 hours total or more
16. Management: High risk patients
    1. Indications
       1. Active ongoing bleeding
       2. Hypotension persists despite Resuscitation
       3. Severe active comorbid condition exascerbation
       4. Liver disease exascerbation
       5. Endotracheal Intubation for airway protection
    2. Protocol
       1. General measures as above
       2. Admit to intensive care unit for first 24 hours
       3. Observe in hospital for 48 to 72 hours or more
       4. Urgent upper endoscopy when stabilized
          1. See Upper Endoscopy Evaluation of GI Bleeding
          2. Consider repeat routine recheck upper endoscopy in 24 hours for high risk lesions
       5. Consider arteriography if source not evident
17. Management: Refractory and Recurrent Bleeding
    1. Indications
       1. Persistent or recurrent bleeding despite EGD
       2. See Upper Endoscopy Evaluation of GI Bleeding
    2. Procedures
       1. Consider arteriography with embolization
          1. First-line study
          2. Equivalent efficacy to surgical intervention
       2. Surgical Intervention
          1. Gastroduodenotomy
          2. Vagotomy
          3. Peptic ulcer resection
18. Management: Disposition
    1. See prevention measures below
    2. See Helicobacter Pylori management
    3. Repeat Upper Endoscopy
       1. Perform at 8-12 weeks after initial endoscopy
       2. Indications
          1. Gastric Ulcer (Confirm healing and exclude cancer)
          2. Severe esophagitis (exclude Barrett's Esophagus)
    4. Iron Deficiency Anemia
       1. Transfused blood will keep Hemoglobin increased only 2-3 weeks
       2. Ferrous Sulfate 325 mg daily to three times daily
          1. Continue until Serum Ferritin and Hemoglobin return to normal
19. Prevention
    1. See Helicobacter Pylori management
    2. Avoid NSAIDs
    3. Consider longterm Proton Pump Inhibitor if Aspirin or Clopidogrel (Plavix) cannot be stopped
       1. See Clopidogrel (Plavix) for potential Proton Pump Inhibitor interactions
    4. Tobacco Cessation
    5. Avoid Alcohol
20. Prognosis: Outcomes
    1. Mortality: 2-15% overall (often related to comorbidity)
       1. In hospital mortality: 13%
       2. Duodenal Ulcer: 3.7%
          1. Higher risk of Erosions into larger vessels
       3. Gastric Ulcer: 2.1%
    2. Course
       1. Bleeding stops and does not recur: 85% (<2% Mortality)
       2. Re-bleeding after initially stopped: 15% (10% Mortality)
       3. Continued active bleed: 5% (30% Mortality)
21. Prognosis: Predictors
    1. Bleeding characteristic predictors of poor outcome
       1. See Upper GI Bleeding Score
       2. Emesis or nasogastric aspirate contains red blood
       3. Low initial Hematocrit
       4. Coagulopathy (Low Platelets or high INR)
    2. Comorbid condition predictors of poor outcome
       1. Active Coronary Artery Disease
       2. Congestive Heart Failure
       3. Active lung disease
       4. Renal Failure
       5. Sepsis
       6. Metastatic cancer
       7. Advanced liver disease
       8. Advanced age
22. References
    1. Gupta (1993) Med Clin North Am 77(5):973-92
    2. Fallah (2000) Med Clin North Am 84(5):1183-208
    3. Longstreth (1995) Am J Gastroenterol 90(2):206-10
    4. Peter (1999) Emerg Med Clin North Am 17(1):239-61
    5. Terdiman (1998) Postgrad Med 103(6):43-64
    6. Wang (2010) Ann Surg 215(1):51-8
    7. Wilkins (2012) Am Fam Physician 85(5): 469-76
    8. Zuckerman (2000) Gastroenterology 118:201-21