Upper Gastrointestinal Bleeding (UGIB)

Causes

• Sleisenger & Fordtran's GI and Liver Disease, p. 304

• PUD - most common cause; linked to H. pylori, NSAIDs, aspirin. Bleeding arises from erosion into submucosal/muscular arteries (mean diameter ~0.7 mm).
• Varices - portosystemic collaterals from portal HTN; in cirrhotics, varices cause 59% of UGI bleeds.
• Mallory-Weiss - longitudinal mucosal tear at the gastroesophageal junction from forceful retching/vomiting, Valsalva maneuver, alcohol binge.
• Dieulafoy lesion - aberrant submucosal artery protruding through mucosa; 80-95% within 6 cm of the GEJ on the lesser curvature.
• Stress ulcers/erosive gastritis - sepsis, trauma, mechanical ventilation, NSAIDs, alcohol.

Clinical Presentation

Initial Assessment & Risk Stratification

Pre-endoscopy Scoring Systems

• Systolic BP, BUN, hemoglobin, heart rate, syncope, melena, liver disease, heart failure
• Score 0 = very low risk (can be managed outpatient)
• Best for identifying patients who need intervention

• Albumin <3.0 g/dL
• INR >1.5
• Altered mental status
• Systolic BP <90 mmHg
• Age >65
• Score <2 = lower mortality risk

Initial Resuscitation

1. Two large-bore IV lines (18G or larger)
2. Fluid resuscitation - crystalloid initially; avoid over-transfusion (liberal transfusion worsens outcomes in variceal bleeding due to increased portal pressure)
3. Blood transfusion - restrictive strategy: transfuse at Hb <7 g/dL (Hb <8 if cardiac disease or active variceal bleed)
4. Massive transfusion protocol if in hemorrhagic shock
5. Airway management - consider early intubation for massive hematemesis, encephalopathy, or inability to protect airway; note: intubation does not improve mortality and has risks
6. Hold anticoagulants/antiplatelets - reverse if needed (e.g., PCC for warfarin, vitamin K)
7. Correct coagulopathy - FFP if INR >1.5, platelets if <50,000

Nasogastric Tube / Lavage

• A positive aspirate (bloody, maroon, or coffee-ground) confirms UGI source
• A negative aspirate does NOT exclude UGI bleed (false-negative in ~23% due to intermittent bleeding, pyloric spasm)
• Room temperature water preferred for lavage
• NG tube placement does NOT provoke variceal bleeding (no evidence to support this concern)
• Tintinalli's Emergency Medicine, p. 538

Endoscopy

• Perform upper endoscopy within 24 hours of presentation after resuscitation (most patients)
• Urgent (<12 hours): active hematemesis, hemodynamic instability despite resuscitation
• Can defer (>24 hours or outpatient): GBS = 0, stable, no high-risk features

Forrest Classification (Endoscopic Risk Stratification)

• Forrest IA, IIA, IIB: require endoscopic hemostasis
• Forrest IIC and III: no endoscopic treatment needed; discharge on oral PPI
• Sleisenger & Fordtran's, p. 306

Endoscopic Hemostasis Techniques

• Injection therapy: epinephrine (1:10,000-20,000) - reduces arterial flow; always combine with a second modality
• Thermal therapy: multipolar electrocoagulation, heater probe, APC (argon plasma coagulation); direct pressure + coagulation to flatten the vessel
• Mechanical: hemoclips placed across the bleeding vessel/NBVV; very effective for Dieulafoy lesions and active arterial bleeders
• Combination therapy (epinephrine + thermal/clip): rebleeding reduced to ~15% vs 30% with monotherapy

Medical Management

Non-variceal Bleed (PPI)

• IV PPI bolus + infusion: omeprazole 80 mg IV bolus then 8 mg/hr x 72 hours (or equivalent)
• Raises intragastric pH >6, stabilizes clot formation
• Started empirically before endoscopy, confirmed/titrated after
• High-dose IV PPI for Forrest IA, IIA, IIB after endoscopic therapy
• Switch to oral PPI after 72 hours

Variceal Bleed (additional measures)

• Vasoconstrictors - octreotide (somatostatin analogue): 50 mcg IV bolus then 25-50 mcg/hr infusion; reduces portal blood flow; start immediately, continue 3-5 days
• Prophylactic antibiotics - ceftriaxone 1g IV daily x 7 days (or norfloxacin 400 mg BID); reduces bacterial infection and rebleeding mortality in cirrhosis
• Endoscopic band ligation (EBL) - preferred over sclerotherapy for acute esophageal varices
• Balloon tamponade (Sengstaken-Blakemore tube) - bridge therapy when endoscopy fails; high complication rate
• TIPS (Transjugular Intrahepatic Portosystemic Shunt) - rescue therapy for refractory variceal bleeding; also used early (within 72 hrs) in high-risk cirrhotics (Child-Pugh C or B with active bleeding)
• Non-selective beta-blocker (propranolol/nadolol or carvedilol) - secondary prophylaxis after acute episode
• Frameworks for Internal Medicine, p. 218

Rebleeding & Failure of Endoscopy

1. Repeat endoscopy - second-look endoscopy in high-risk patients; can attempt hemostasis again
2. Interventional radiology - angiography with transcatheter arterial embolization (TAE); for non-variceal bleeding not amenable to endoscopy
3. Surgery - increasingly rare but still needed for:
   • Posterior duodenal ulcer eroding into the gastroduodenal artery
   • Failed endoscopic + radiologic therapy
   • Hemodynamic instability unable to be controlled

Post-Acute Management

• Test and treat H. pylori if PUD confirmed (eradication markedly reduces recurrence)
• Avoid NSAIDs; if unavoidable, use with PPI cover
• Continue PPI orally (at least 4-8 weeks for PUD)
• Repeat endoscopy in 6-8 weeks for gastric ulcers (to confirm healing and exclude malignancy)
• Variceal bleed survivors: start beta-blocker + repeat EBL every 1-4 weeks until variceal eradication; consider TIPS evaluation

Prognosis

• Bleeding is self-limited in 80% without specific therapy
• Of the 20% who rebleed or have persistent bleeding: mortality is 30-40%
• Predictors of poor outcome: active arterial bleeding at endoscopy, large ulcer (>2 cm), posterior duodenal wall location, Hb <10, hemodynamic instability, age >65, cirrhosis, renal failure
• Sleisenger & Fordtran's, p. 304-305