Upper Gastrointestinal Hemorrhage

Upper gastrointestinal hemorrhage is bleeding which occurs from a source located proximal to the ligament of Treitz. There are multiple sources of this type of bleeding. The most common cause of significant upper gastrointestinal bleeding is peptic ulcer disease. Generally, duodenal ulcer disease is a more frequent cause of bleeding than gastric ulcer.

Presentation
History should provide a fairly accurate estimation of the source of upper GI bleeding. Information pertaining to previous episodes of bleeding is of obvious importance. The presence of concurrent diseases such as hepatic disease, alcoholism, peptic ulcer disease, and hematological disorders may provide additional clues. For example, a patient who reports chronic upper abdominal pain and ingestion of large amounts of NSAIDS probably has a gastric ulcer or erosive gastritis.

The manner in which the bleeding presents can provide clues to its source. For example, hematemesis of either bright red blood or “coffee grounds” suggests a bleeding source proximal to the ligament of Treitz. The presence of “coffee grounds” indicates that the hemoglobin has been in contact with gastric acid long enough to be converted to methemoglobin. Hematochezia, the passage of bright red blood per rectum, suggests a distal lower gastrointestinal source of bleeding. Alternatively, massive upper GI hemorrhage can present as hematochezia. Otherwise, upper GI bleeding typically produces melena. This indicates that the blood has been in the GI tract for a longer period of time.

Physical exam may also provide information that can suggest the likely cause of bleeding. Stigmata of portal hypertension (e.g., ascites, jaundice, caput medusa, palmar erythema, etc.) may point to esophageal varices as a likely cause of bleeding. Cachexia, an abdominal mass, and an enlarged Virchow’s node may suggest underlying malignancy.

Diagnosis
It is important to identify the cause and location of upper GI bleeding. After the patient is resuscitated, upper endoscopy is performed to allow for identification of the bleeding site. In most cases this can be successfully accomplished. In addition, therapeutic measures such as heater coagulation, epinephrine injection, and variceal banding can be performed at the same setting after diagnosis is confirmed. Before upper endoscopy can be performed, placement of a nasogastric tube can help distinguish upper GI bleeding from lower. Basically, a bleeding site proximal to the ligament of Treitz is suggested when blood is aspirated from a properly placed nasogastric tube. Angiography and tagged red blood cell scan can also help to identify the site of bleeding but are not commonly needed in cases of upper gastrointestinal hemorrhage.

Treatment
Immediate resuscitation is the first treatment priority with upper GI bleeding. The volume of blood loss can be deduced by physical findings. Tachycardia and narrowing of the pulse pressure are sensitive early indicators of blood loss. Orthostatic hypotension and subtle mental status changes may be present. Hypotension and oliguria are late signs which indicate a large volume of blood loss. The patient’s physiologic response to volume infusion is important. Persistent tachycardia despite volume resuscitation is an ominous sign of significant ongoing hemorrhage.

Nasogastric tube placement and gastric lavage are performed to remove pooled blood, which reduces fibrinolysis at bleeding sites. Lavage and evacuation of the stomach also prevent gastric distention, which predisposes the patient to vomiting and aspiration. Gastric distention also stimulates gastrin release. Correction of coagulopathy is essential when present. Blood transfusion is performed when necessary.

Gastric pH should be mainained at >5.0 with antacids, H2 blockers, or proton pump inhibitors. This usually does not stop ongoing bleeding but is necessary to limit progression of disease and allow for healing. Endoscopic electrocautery or epinephrine injection may be attempted with bleeding ulcers or gastritis. Sclerotherapy or endoscopic banding may be attempted with variceal bleeding. Angiographic embolization does not work well because of the rich submucosal vascular plexus of the stomach. Selective infusion of vasopressin into the left gastric artery may lead to a temporary response.

Surgical Management
Surgical treatment is indicated in cases where medical treatment fails to lead to cessation of bleeding. Fortunately, most upper GI hemorrhage will cease with conservative measures. Certain patient characteristics may lead one to consider surgery earlier. For instance, large ulcers with a visible vessel in the base are likely to experience significant rebleeding and probably should be operated on. In addition, patients with significant cardiac disease in whom bleeding would be poorly tolerated may be considered earlier for surgery. Other considerations for early surgery would be an existing contraindication to transfusion (e.g., Jehovah’s witness), a difficult cross-match, or flow-dependent cerebrovascular disease.