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upper gastrointestinal hemorrhage

Upper gastrointestinal (GI) hemorrhage refers to bleeding proximal to the jejunum (or ligament of Treitz). Mortality may be as high as 10%. Etiology: - peptic ulcer* (34%) - duodenal ulcer - gastric ulcer - erosive gastritis (13%), NSAID use, H pylori infection - stress ulceration - anticoagulation [3] - esophageal varices*, gastric varices* (33%) - due to portal hypertension, cirrhosis [3] - erosive esophagitis (8%) - Mallory-Weiss tear (6%) - hematemesis after heavy alcohol use, hematemesis after weightlifting, bulemia [3] - angiodysplasia (gastric & duodenal) (<6%) - pyloric channel ulcer (2%) - gastric antral vascular ectasia - neoplasm (5%) - gastric neoplasm* - esophageal neoplasm* - gastrointestinal stromal tumor* - metastatic tumor to the duodenum - gastric polyps - erosive duodenitis (2%) - Dieulafoy's lesion* (1%) - Cameron erosion - anastomotic ulcer - aortoenteric fistula* (patients with aortic graft surgery) - hematobilia* - Menetrier's disease - Schonlein-Henoch purpura - Osler-Weber-Rendu syndrome - celiac disease - hemosuccus pancreaticus - idiopathic (13%) * causes of severe upper GI bleed [3] Epidemiology: - more common than lower GI bleed [3] Clinical manifestations: 1) hematemesis 2) coffee-ground emesis 3) melena 4) infrequently, bright-red-blood per rectum [3] Laboratory: 1) (see gastrointestinal hemorrhage) 2) serum creatinine, serum urea nitrogen - BUN/creatinine ratio of > 30 suggests upper GI bleed 3) H. pylori serology or other H. pylori testing if biopsy negative for H pylori Special laboratory: 1) Glasgow-Batchford score (range 0-23) - when score = 0, 100% negative predictive value for severe GI bleed & need for hospitalization [3] 2) upper GI endoscopy, esophagogastroduodenoscopy (EGD) a) after hemodynamic stabilization [3] b) within 24 hours [5] c) within 12 hours if esophageal varices suspected [3] d) routine 2nd look not recommended [3,5] e) endoscopic coagulation or injection for - actively bleeding ulcers - visble vessels - sentinal clots f) endoscopic ligation or sclerosis of esophageal varices g) mechanical (clips) vs thermal hemostasis with similar outcomes [6] h) biopsy for Helicobacter pylori 3) capsule endoscopy - repeat esophagogastroduodenoscopy with biopsies & colonoscopy or push enteroscopy indicated prior capsule endoscopy if initial studies were of low quality [3] Radiology: - CT angiography for hemodynamically unstable patients with small bowel bleeding [3] - technetium labeled nuclear scan (scintigraphy) provides the best sensitivity for actively bleeding lesion not detected by upper or lower GI endoscopy or capsule endoscopy [3] - arteriography a) failure of EGD to visualize source of bleeding b) bleeding of > 0.5 mL/min at the time of study c) arterial angiotherapy 1] vasopressin 0.15-2.0 units/min in selectively catheterized bleeding artery 2] arterial embolization - selective arterial catheterization - absorbable gelatin powder (Gelfoam) - upper GI with barium has no role in initial evaluation of active upper GI bleed Complications: - higher mortality than lower GI bleed - mortality (up to 14%) - tachycardia (> 100/min), hypotension (systolic BP < 100 mm Hg), age > 60 years, comorbidities associated with increased risk for rebleeding & increased mortality [3] Management: 1) general recommendations: [8] a) 2 large caliber IV catheters b) IV crystalloids: target heart rate < 100/min, systolic BP > 100 mm Hg c) transfuse patients with hemoglobin <7 g/dL in the absence of shock or symptomatic anemia [9,10,17]; < 8 g/dL [23]; - target 7-9 g/dL [3] d) perform endoscopy early (within 24 hours) for most patients - stabilize patients hemodynamically with fluids & erythrocytes prior to endoscopy - endoscopy within 12 hours if esophageal varices suspected [3] - endoscopy within 6 hours no better thqn later endoscopy [24] e) do not delay endoscopy to correct coagulopathies or to administer proton-pump inhibitor (PPI) therapy to downsize lesions f) if endoscopic treatment fails, percutaneous embolization can be considered as an alternative to surgery g) bolus- & continuous-infusion PPI for high-risk patients for 3 days after successful endoscopy for high-risk peptic ulcer or adherent clots [3] - proton pump inhibitor of no benefit for acute peptic ulcer bleeding or other cause of acute upper GI bleed before [11] or after endoscopy [12] - H2 receptor blockers are not beneficial h) hospitalize high-risk patients at least 72 hours - Glasgow-Blatchford score <= 1 predicts low-risk patients [18] i) discharge low-risk patients soon after endoscopy - see peptic ulcer to "low risk" criteria - no benefit of observing for 24 hours in hospital [3] j) prescribe daily proton pump inhibitor at discharge k) in patients with peptic ulcers, test for, treat, & eradicate Helicobacter pylori [5,8] l) nonspecific NSAIDs plus a proton pump inhibitor or a COX2 inhibitor alone associated with bleeding risk; COX-2 inhibitor plus a PPI recommended if NSAID required m) restart low-dose aspirin for cardiovascular prophylaxis as soon as benefit outweighs bleeding risk - restarting low-dose aspirin 3-5 days after upper GI bleed reduces 30-day mortality 10-fold in patients with cardiovascular disease, while increasing rebleeding rates only 2-fold [3] - clopidogrel confers higher risk aspirin plus a proton pump inhibitor [8] n) restart anticoagulation after resolution of bleeding [3] m) use prognostic scales to assess risk for rebleeding & death 2) general measures (see gastrointestinal hemorrhage) a) do not insert nasogastric tube for aspiration to confirm diagnosis [3] b) also see algorithm for management of GI bleed 3) Minnesota Esophagogastric Tamponade Tube for acute bleeding refractory to other measures (see esophageal varices) 4) esophagogastroduodenoscopy (EGD) see above a) stabilize patients hemodynamically with fluids & erythrocytes prior to endoscopy b) IV bolus of proton pump inhibitor before endoscopy, followed by infusion after EGD [2, 5] c) octreotide 50 ug IV bolus, then 25-50 ug/hour IV drip (superior to vasopressin) - for use in conjunction with EGD - octreotide alone does not improve outcome of non- esophageal varices upper GI bleed [3] d) H2-receptor antagonists are NOT effective in stopping active UGI bleed 5) therapy for specific lesions a) peptic ulcer: - continue proton pump inhibitor only if peptic ulcer is the source of bleeding [3] b) esophageal varices c) Mallory-Weiss tear d) aortoenteric fistula e) angiodysplasia 6) empiric prophylactic therapy with broad-spectrum antibiotics is indicated in patients with cirrhosis [3] 7) prognosis - patients taking NSAIDs at the time of hemorrhage - switching to COX-2 inhibitor or adding omeprazole to NSAID results in similar rebleed rate = 5% [4] 8) prophylaxis - proton pump inhibitor reduces risk of GI bleed associated with anti-platelet agent [7]

Related

aortoenteric fistula; aortoduodenal fistula comorbid conditions that increase mortality of upper GI bleed esophageal varices melena Minnesota esophagogastric tamponade tube octreotide (Sandostatin) peptic ulcer disease (PUD) stress ulceration upper gastrointestinal (GI) endoscopy; esophagogastroduodenoscopy (EGD)

Specific

Dieulafoy's lesion Esophageal Hemorrhage hematemesis hemosuccus pancreaticus Mallory-Weiss tear small intestinal hemorrhage

General

gastrointestinal hemorrhage

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 300-302
  2. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 346-353
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2021 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Journal Watch 23(3):25-26, 2003 Chan FKL et al, N Engl J Med 347:2104, 2002 PMID: 12501222
  5. Journal Watch 24(2):20, 2004 Barkun A, Bardou M, Marshall JK; Nonvariceal Upper GI Bleeding Consensus Conference Group. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2003 Nov 18;139(10):843-57. PMID: 14623622
  6. Saltzman JR, Strate LL, Di Sena V, Huang C, Merrifield B, Ookubo R, Carr-Locke DL. Prospective trial of endoscopic clips versus combination therapy in upper GI bleeding (PROTECCT--UGI bleeding). Am J Gastroenterol. 2005 Jul;100(7):1503-8. PMID: 15984972 (appears that guideline associated with this reference has been withdrawn in Dec 2009)
  7. Ibanez L, Vidal X, Vendrell L, Moretti U, Laporte JR; Spanish- Italian Collaborative Group for the Epidemiology of Gastrointestinal Bleeding. Upper gastrointestinal bleeding associated with antiplatelet drugs. Aliment Pharmacol Ther. 2006 Jan 15;23(2):235-42. PMID: 16393302
  8. Barkun AN et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010 Jan 19; 152:101. PMID: 20083829
  9. Villanueva C et al Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2013; 368:11-21January 3, 2013 PMID: 23281973 http://www.nejm.org/doi/full/10.1056/NEJMoa1211801
  10. Villanueva C et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013 Jan 3; 368:11 PMID: 23281973 - Laine L. Blood transfusion for gastrointestinal bleeding. N Engl J Med 2013 Jan 3; 368:75. PMID: 23281980
  11. The NNT: Proton Pump Inhibitors (PPIs) Given for Acute Upper Gastrointestinal Bleeding Given Prior to Endoscopic Diagnosis. http://www.thennt.com/nnt/proton-pump-inhibitors-for-acute-upper-gi-bleeding/ - Sreedharan A, Martin J, Leontiadis GI et al Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD005415 PMID: 20614440
  12. The NNT: Proton Pump Inhibitors (PPIs) Given for Acute Peptic Ulcer Bleeding http://www.thennt.com/nnt/proton-pump-inhibitors-for-acute-peptic-ulcer-bleeding/ - Leontiadis GI, McIntyre L, Sharma VK, Howden CW. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004;(3):CD002094 PMID: 15266462
  13. Kim JJ, Sheibani S, Park S, Buxbaum J, Laine L. Causes of bleeding and outcomes in patients hospitalized with upper gastrointestinal bleeding. J Clin Gastroenterol. 2014 Feb;48(2):113-8. PMID: 23685847
  14. Hwang JH, Fisher DA, Ben-Menachem T et al The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc. 2012 Jun;75(6):1132-8 PMID: 22624808 (corresponding NGC guideline withdrawn Dec 2017)
  15. Srygley FD, Gerardo CJ, Tran T, Fisher DA. Does this patient have a severe upper gastrointestinal bleed? JAMA. 2012 Mar 14;307(10):1072-9. Review. PMID: 22416103
  16. Laine L Upper Gastrointestinal Bleeding Due to a Peptic Ulcer. N Engl J Med 2016; 374:2367-2376. June 16, 2016 PMID: 27305194 http://www.nejm.org/doi/full/10.1056/NEJMcp1514257
  17. Bjorkman DJ No Adverse Postdischarge Outcomes of Low Discharge Hemoglobin for UGIB. NEJM Journal Watch. Aug 3 2016 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Lee JM, Kim ES, Chun HJ et al. Discharge hemoglobin and outcome in patients with acute nonvariceal upper gastrointestinal bleeding. Endosc Int Open 2016 Jul 21 PMID: 27540574 Free PMC Article https://www.thieme-connect.de/DOI/DOI?10.1055/s-0042-110176
  18. Stanley AJ, Laine L, Dalton HR et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: International multicentre prospective study. BMJ 2017 Jan 4; 356:i6432. PMID: 28053181 Free PMC Article http://www.bmj.com/content/356/bmj.i6432
  19. Singh M, Koyfman A, Martinez JP. Abdominal Vascular Catastrophes. Emerg Med Clin North Am. 2016 May;34(2):327-39. Review. PMID: 27133247
  20. Fortinsky KJ, Bardou M, Barkun AN. Role of Medical Therapy for Nonvariceal Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am. 2015 Jul;25(3):463-78. Review. PMID: 26142032
  21. Sey MSL, Mohammed SB, Brahmania M, Singh S, Kahan BC, Jairath V. Comparative outcomes in patients with ulcer- vs non-ulcer-related acute upper gastrointestinal bleeding in the United Kingdom: A nationwide cohort of 4478 patients. Aliment Pharmacol Ther 2019 Jan 9 PMID: 30628112 https://onlinelibrary.wiley.com/doi/full/10.1111/apt.15092
  22. Shung DL, Au B, Taylor RA et al. Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding. Gastroenterology 2019 Sep 25; PMID: 31562847 https://www.gastrojournal.org/article/S0016-5085(19)41342-5/pdf
  23. Barkun AN, Almadi M, Kuipers EJ et al Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019. Oct 22. PMID: 31634917 https://annals.org/aim/fullarticle/2753604/management-nonvariceal-upper-gastrointestinal-bleeding-guideline-recommendations-from-international-consensus - Lanas A International Consensus Guidelines for Nonvariceal Gastrointestinal Bleeding: A Step Forward. Ann Intern Med. 2019. Oct 22. PMID: 31634918 https://annals.org/aim/article-abstract/2753605/international-consensus-guidelines-nonvariceal-gastrointestinal-bleeding-step-forward
  24. Lau JYW, Yu Y, Tang RSY et al Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2020; 382:1299-1308. April 2. PMID: 32242355 https://www.nejm.org/doi/full/10.1056/NEJMoa1912484 - Laine L Timing of Endoscopy in Patients Hospitalized with Upper Gastrointestinal Bleeding N Engl J Med 2020; 382:1361-1363. April 2. PMID: 32242363 https://www.nejm.org/doi/full/10.1056/NEJMe2002121
  25. Sengupta N et al. The role of imaging for gastrointestinal bleeding: Consensus recommendations from the American College of Gastroenterology and Society of Abdominal Radiology. Am J Gastroenterol 2024 Mar; 119:438. PMID: 38857483 https://journals.lww.com/ajg/fulltext/2024/03000/the_role_of_imaging_for_gastrointestinal_bleeding_.15.aspx - Sengupta N, Kastenberg DM, Bruining DH et al The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations. Radiology. 2024 Mar;310(3):e232298. PMID: 38441091 Review.