Upper Gastrointestinal (GIT) Bleeding - Complete Clinical Review

CAUSES / ETIOLOGY

IMPORTANT HISTORY POINTS

• Hematemesis - bright red blood in vomitus = active or recent bleeding
• Coffee-ground emesis - digested blood, suggests slower or stopped bleeding
• Melena - black, tarry, malodorous stools - strongly suggests UGIB (especially in patients <50 years)
• Hematochezia - bright red blood per rectum - can arise from UGIB in ~14% of cases when bleeding is massive and rapid

1. Prior GI bleeding episodes - up to 60% of recurrent UGIBs arise from the same lesion
2. History of peptic ulcer disease or H. pylori infection
3. Alcohol use and liver disease - cirrhotic patients have a 30% chance of variceal bleeding; ~60% rebleed within 12 months
4. NSAID / aspirin / anticoagulant use - most patients presenting with UGIB used aspirin or an NSAID in the preceding week; half use these OTC
5. Retching and vomiting before hematemesis - classic for Mallory-Weiss tear (also seen with DKA, chemotherapy, alcohol binge)
6. History of aortic graft surgery - "herald bleed" (self-limited initial hematemesis) preceding massive hemorrhage = aortoenteric fistula
7. Iron or bismuth ingestion - can simulate melena (stool guaiac will be negative)
8. Red-dye liquids or beets - can simulate hematochezia
9. Smoking, alcohol, GERD - risk factors for esophageal cancer
10. Known varices, prior TIPS, banding - high-risk endoscopic history
11. Syncope, weakness, angina, confusion - may be the only presenting feature without overt bleeding

CLINICAL FEATURES

Symptoms

• Hematemesis (bright red or coffee-ground)
• Melena
• Hematochezia (in massive UGIB)
• Syncope, dizziness, weakness
• Angina or palpitations (demand ischemia from blood loss)

Signs - Vital Signs

• Tachycardia (often first sign)
• Hypotension / orthostatic hypotension
• Decreased pulse pressure
• Tachypnea
• Paradoxical bradycardia can occur even with significant hemorrhage
• Younger patients without comorbidities may tolerate substantial volume loss with minimal vital sign changes

Signs - Physical Examination

• Pallor, cool clammy extremities (hypovolemia)
• Jaundice, spider angiomas, palmar erythema, splenomegaly, ascites - suggest liver disease and variceal bleeding
• Epigastric tenderness - suggests peptic ulcer disease
• Digital rectal exam - assess stool color (melena vs. hematochezia) and confirm rectal bleeding

Postural (Orthostatic) Vital Signs

• Drop in systolic BP >10 mmHg OR rise in HR >20 bpm on standing suggests >15% volume loss

INVESTIGATIONS

Bedside / Initial Assessment

• Nasogastric aspirate (NG tube) - red blood or coffee-ground material confirms UGIB; useful when diagnosis is not clinically apparent (no strong evidence it provokes variceal bleeding)
• Stool guaiac / FOBT - confirms blood in stool; differentiates true melena from iron/bismuth ingestion

Laboratory Studies

Scoring Systems (Risk Stratification)

• Predicts need for clinical intervention (transfusion, endoscopy, surgery)
• Score 0 = very low risk; can consider outpatient management

• Albumin <3.0 g/dL
• INR >1.5
• Mental status alteration
• Systolic BP <90 mmHg
• Age >65 years
• Score ≥2 = higher mortality, longer stay, higher cost

• Score 0-2 = low risk, consider early discharge
• Correlates well with mortality

Imaging and Endoscopy

1. Upper GI Endoscopy (EGD) - gold standard - diagnostic AND therapeutic
   • Perform within 24 hours of presentation in most patients with overt bleeding after adequate resuscitation
   • Identifies stigmata of recent haemorrhage (SRH): active spurting, visible vessel, adherent clot, flat spot, clean base
   • Can be performed urgently (<12 hours) in haemodynamically unstable or high-risk patients
   • Side-viewing duodenoscope for suspected duodenal/ampullary bleeding not seen on standard scope
2. CT angiography (CTA) - when endoscopy is non-diagnostic or not feasible; detects bleeding >0.3-0.5 mL/min
3. Mesenteric angiography - for active bleeding; can be therapeutic (coil embolization)
4. Scintigraphy (tagged RBC scan) - detects slow intermittent bleeding (>0.1 mL/min)

MANAGEMENT

Step 1: Immediate Resuscitation ("ABC" First)

• Airway - consider prophylactic endotracheal intubation if massive active bleeding, altered consciousness, or aspiration risk; use smaller induction agent doses to minimize peri-intubation hypotension
• IV access - two large-bore IVs (16-gauge or larger)
• IV fluids - crystalloid resuscitation while awaiting blood products
• Oxygen - supplemental O2 in all patients

Step 2: Blood Transfusion

• Correct coagulopathy: FFP if INR elevated; platelets if <50,000; vitamin K if on warfarin
• Correct thrombocytopenia aggressively in active bleeding

Step 3: Pharmacological Treatment

Step 4: Endoscopic Therapy (Definitive for Most)

• Injection therapy - adrenaline/epinephrine injection (local vasoconstriction + tamponade), tissue adhesives (e.g., cyanoacrylate for gastric varices)
• Mechanical therapy - hemostatic clips, band ligation (variceal banding), suturing devices
• Thermal therapy:
  • Contact: electrocoagulation, thermocoagulation (heater probe)
  • Non-contact: argon plasma coagulation (APC), Nd:YAG laser photocoagulation
• Combination therapy (e.g., epinephrine + thermal/clip) is superior to monotherapy for high-risk lesions

• Esophageal varices - endoscopic band ligation (EBL) is first-line
• Gastric varices - cyanoacrylate glue injection or thrombin

Step 5: Management of Refractory Bleeding

Step 6: Secondary Prevention

• H. pylori eradication - test-and-treat in all peptic ulcer bleeders
• Stop NSAIDs - if not possible, add PPI prophylaxis
• PPI long-term - for high-risk ulcers or ongoing NSAID use
• Beta-blockers (propranolol/carvedilol) + EBL - for variceal bleed secondary prevention
• TIPS - for refractory or recurrent variceal bleeding in cirrhosis

RISK STRATIFICATION SUMMARY

KEY PROGNOSTIC FACTS

• Bleeding is self-limited in 80% of UGIB patients even without specific therapy
• Of the remaining 20% who rebleed, mortality is 30-40%
• Overall UGIB mortality is 5-10% (unchanged since the 1970s despite advances, due to older and sicker patient population)
• Variceal bleeding carries 20% mortality per episode; ~60% rebleed within 12 months
• Peptic ulcer most common cause (~35-50%); varices carry highest per-episode mortality

RECENT EVIDENCE UPDATES