Upper gastrointestinal bleeding

Persons with upper gastrointestinal bleeding often present with hematemesis, coffee ground vomiting, melena, or hematochezia (maroon-coloured stool) if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage. A person with upper gastrointestinal bleeding 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: • Vital signs, in order to determine the severity of bleeding and the timing of intervention • Abdominal and rectal examination, in order to determine possible causes of hemorrhage • Assessment for portal hypertension and stigmata of chronic liver disease in order to determine if the bleeding is from a variceal source. Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio. ==Causes==

of stomach with overlying clot. Pathology was consistent with gastric lymphoma. A number of medications increase the risk of bleeding including NSAIDs and SSRIs. SSRIs double the rate of upper 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==

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. Prokinetic agents to empty the stomach such as erythromycin before endoscopy can decrease the amount of blood in the stomach and thus improve the operators view. This erythromycin treatment may lead to a small decrease in the need for a blood transfusion, but the overall balance of how effective erythromycin is compared to potential risks is not clear. Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found. It is also recommended that people with high risk signs are kept in hospital for at least 72 hours. Blood transfusions are not generally recommended to correct anemia, but blood transfusions are recommended if the person is not stable (cardiovascular system instability). Oral iron can be used, but this can lead to problems with compliance, tolerance, darkening stools which may mask evidence of rebleeding and tends to be slow, especially if used in conjunction with proton pump inhibitors. Parenteral Iron is increasingly used in these cases to improve patient outcomes and void blood usage. ==Prognosis==

Depending on its severity, upper gastrointestinal bleeding may carry an estimated mortality risk of 11%. 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==