What are the common causes?
How should patients be assessed?
What are the treatment options?
* UPPER GI BLEEDING IS A COMMON MEDICAL EMERGENCY WITH AN INCIDENCE IN THE UK OF 103 cases per 100,000 adults per year and is much more common in the elderly. (1)
A national audit by the British Society of Gastroenterology (BSG) on the management of upper GI bleeding in the UK, conducted between 1993 and 1994, showed 30-day mortality to be 14%. (2) Based on this audit several recommendations were made, including urgent endoscopy in high-risk patients and admission or early referral of patients with upper GI bleeding to gastroenterology teams. However, despite improvements in endoscopy, recognition of provoking factors and pharmacological interventions available when the audit was repeated in 2007 the mortality rate still remained significant at 10%. (3)
The most common presenting signs of acute upper GI bleeding are haematemesis, either bright red or 'coffee ground', and melaena. About 30% of patients with bleeding ulcers present with haematemesis, 20% with melaena, and 50% with both. Haematochezia usually suggests a lower GI source of bleeding, however, up to 5% of patients with bleeding ulcers have haematochezia and it indicates heavy bleeding into the upper GI tract. (4) An upper GI bleeding source should be considered when haematochezia presents with signs and symptoms of haemodynamic compromise such as syncope, postural hypotension, tachycardia, and shock should therefore direct one's attention to an upper GI source of bleeding.
More insidious presentations would include nausea, vomiting, epigastric pain, vasovagal phenomena, and syncope, however systemic symptoms such as these would be rare without a history of melaena.
Peptic ulcer disease, both gastric and duodenal, accounts for the majority of admissions for upper GI bleeding, see table 1, above. Significant bleeding can result from involvement of large vessels within the base of the ulcer see figure 1, p15. (3) The main risk factors for developing peptic ulcers are a history of NSAID use (5) or the presence of Helicobacter pylori infection. (6) Warfarin and clopidogrel use can potentiate bleeding, however clopidogrel can also induce bleeding independently in patients with previous peptic ulcer disease. (7)
Bleeding from oesophageal varices usually results in large volumes of bright red haematemesis, if a previous history of chronic liver disease (with or without varices) is known or signs of chronic liver disease are present then an upper GI bleed should be treated as a serious emergency regardless of cardiovascular stability.
Other causes of bleeding are listed in table 1, above, these include a mucosal (Mallory-Weiss) tear of the gastro-oesophageal junction secondary to vomiting, and multiple types of vascular abnormalities. Apart from variceal disease all other causes can vary in severity and with assessment and risk stratification appropriate initial management, early endoscopy or early discharge can be planned.
Clinical risk factors for mortality in upper GI bleeding are: age; comorbidity; tachycardia and a low systolic blood pressure and should be assessed at presentation. The Rockall scoring system incorporates these clinical...
You Are Viewing A Preview Page of the Full ArticleThe article found is from the Academic OneFile database.
You may need to log in through your institution or contact your library to obtain proper credentials.