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Encyclopedia > Upper gastrointestinal bleeding
Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper GI hemorrhage.
Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper GI hemorrhage.

Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the splenic flexure of the colon. Image File history File linksMetadata DU_2. ... Image File history File linksMetadata DU_2. ... To meet Wikipedias quality standards, this article or section may require cleanup. ... The gastrointestinal tract or digestive tract, also referred to as the GI tract or the alimentary canal or the gut, is the system of organs within multicellular animals which takes in food, digests it to extract energy and nutrients, and expels the remaining waste. ... It has been suggested that Treitz ligament be merged into this article or section. ... In anatomy of the digestive system, the duodenum is a hollow jointed tube connecting the stomach to the jejunum. ... Grays Fig. ... In anatomy of the digestive system, the colon, also called the large intestine or large bowel, is the part of the intestine from the cecum (caecum in British English) to the rectum. ...


Upper GI bleeds are considered medical emergencies, and require admission to hospital for urgent diagnosis and management. Due to advances in medications and endoscopy, upper GI hemorrhage is now usually treated without surgery. A medical emergency is an injury or illness that poses an immediate threat to a persons health or life which requires help from a doctor or hospital. ... A physician visiting the sick in a hospital. ... Proton pump inhibitors are a group of drugs whose main action is pronounced and long-lasting reduction of gastric acid production. ... Endoscopic images of a duodenal ulcer Endoscopy means looking inside and refers to looking inside the human body for medical reasons. ...

Contents

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Clinical presentation

Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, maroon stool, or hematochezia if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage. Hematemesis or haematemesis is the vomiting of fresh red blood. ... Coffee ground vomiting refers to a particular appearance of vomit. ... In medicine, melena or melaena refers to the black, tarry feces that are associated with gastrointestinal hemorrhage. ... Hematochezia is the passage of bright red blood from the rectum, with or without feces. ...


Patients may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath. This article discusses the medical condition. ... Syncope has two distinct and apparantly unrelated meanings, one in linguistics and another in medicne. ... Fatigue may refer to: Fatigue (physical) - tiredness in humans Fatigue (material) - failure by repeated stress in materials Fatigues (uniform) - military uniform (BDU or ACU) Chronic Fatigue Syndrome - a medical condition Battle fatigue - also known as Post-traumatic stress disorder Readers fatigue - a side-effect of parsing poorly formatted textual...


The physical examination performed by the physician concentrates on the following things: In medicine, the physical examination or clinical examination is the process by which the physician investigates the body of a patient for signs of disease. ... Physician examining a child A physician is a person who practices medicine. ...

Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio. Vital signs are often taken by health professionals in order to assess the most basic body functions. ... The abdomen is a part of the body. ... The posterior aspect of the rectum exposed by removing the lower part of the sacrum and the coccyx. ... In medicine, portal hypertension is hypertension (high blood pressure) in the portal vein and its branches. ... Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrotic scar tissue as well as regenerative nodules, leading to progressive loss of liver function. ... This article discusses the medical condition. ... This page is a candidate to be moved to Wiktionary. ... In medicine, the BUN-to-creatinine ratio, also BUN-creatinine ratio and BUN/creatinine ratio, is a ratio of two laboratory test values, the blood urea nitrogen (BUN) and serum creatinine. ...

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Causes

There are many causes for upper GI hemorrhage. Causes are usually anatomically divided into their location in the upper gastrointestinal tract.


Patients are usually stratified into having either variceal or non-variceal sources of upper GI hemorrhage, as the two have different treatment algorithms and prognosis. In medicine (gastroenterology), esophageal varices are extreme dilations of sub mucosal veins in the mucosa of the esophagus in diseases featuring portal hypertension, secondary to cirrhosis primarily. ...

Gastric ulcer in antrum of stomach with overlying clot. Pathology was consistent with gastric lymphoma. Reproduced with permission of patient
Gastric ulcer in antrum of stomach with overlying clot. Pathology was consistent with gastric lymphoma. Reproduced with permission of patient

The causes for upper GI hemorrhage include the following: Image File history File links MALT_4. ... Image File history File links MALT_4. ... In Biology, Antrum is a general term for a cavity or chamber which may have specific meaning in reference to certain organs or sites in the body. ... In anatomy, the stomach (in ancient Greek στόμαχος) is an organ in the gastrointestinal tract used to digest food. ... Endoscopic image of gastric MALT lymphoma taken in body of stomach in patient who presented with upper GI hemorrhage. ...

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The esophagus (also spelled oesophagus/œsophagus), or gullet is the muscular tube in vertebrates through which ingested food passes from the mouth area to the stomach. ... In medicine (gastroenterology), esophageal varices are extreme dilations of sub mucosal veins in the mucosa of the esophagus in diseases featuring portal hypertension, secondary to cirrhosis primarily. ... Esophagitis (or Oesophagitis) is inflammation of the esophagus. ... Esophageal cancer is malignancy of the esophagus. ... In anatomy, the stomach (in ancient Greek στόμαχος) is an organ in the gastrointestinal tract used to digest food. ... In medicine, stomach cancer (also called gastric cancer) can develop in any part of the stomach and may spread throughout the stomach and to other organs. ... Gastritis is a medical term for inflammation of the lining of the stomach. ... Gastric varices are dilated submucosal veins in the stomach. ... Gastric antral vascular ectasia (GAVE, also called watermelon stomach) is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anemia. ... Dieulafoys lesion is an uncommon cause of gastric bleeding thought to cause less then 5% of all gastro-intestinal bleeds in adults. ... In anatomy of the digestive system, the duodenum is a hollow jointed tube connecting the stomach to the jejunum. ... Hemosuccus pancreaticus, also known as pseudohematobilia or Wirsungorrhage is a rare cause of hemorrhage in the gastrointestinal tract. ... A duct joining the pancreas to the bile duct to supply pancreatic juice which aid in digestion provided by the exocrine pancreas. ...

Diagnosis

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Summary

The diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more. In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using the Gastroccult test.

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Details

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Prevalence of upper GI bleeding

About 75% of patients presenting to the emergency room with GI bleeding have an upper source[1]. The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of patients in the emergency room with GI bleeding have an upper source[2][3][4]. Determining whether a patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult. Lower gastrointestinal bleeding refers to any form of bleeding in the Lower gastrointestinal tract. ...

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Diagnostic testing

Whiting studied a cohort of 325 patients and found the odds ratios for the strongest predictors were: black stool, 16.6 (95% confidence interval [CI], 7.7-35.7); age < 50 years, 8.4 (95% CI, 3.2-22.1); and blood urea nitrogen/creatinine ratio 30 or more, 10.0 (95% CI, 4.0-25.6)[5]. Seven (5%) of 151 with none of these factors had an upper GI tract bleed, versus 63 (93%) of 68 with 2 or 3 factors. Ernst found similar results [6].


The nasogastric aspirate can help determine the location of bleeding and thus direct initial diagnostic and treatment plans. Witting found that nasogastric aspirate has sensitivity 42%, specificity 91%, negative predictive value 64%, positive predictive value 92% and overall accuracy of 66% in differentiating upper GI bleeding from bleeding distal to the ligament of Treitz[7]. Thus, a positive aspirate is more helpful than a negative aspirate. In a smaller study, Cuellar found a sensitivity of 79% and specificity of 55% [8]. Cuellar also studied the appearance of the aspirate and a summary of these results is available at the Evidence-Based On-Call database. Although the website lists these results as expired, they were available as of Oct, 16, 2006. These results are also available through the Wayback Archive and readers may consult the Archive if the original page is removed. It has been suggested that Treitz ligament be merged into this article or section. ...


Determining whether blood is in gastric contents, either vomited or aspirated specimens, is surprisingly difficult. Slide tests are based on orthotolidine (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). Rosenthal found orthotolidine-based tests to be more sensitive than specific; the Hemoccult test to have sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate [9]. Cuellar found the following results:

Determining whether blood is in the gastric aspirate [10]
Finding Sensitivity Specificity Positive predictive value (prevalence of 39%)
Gastroccult 95% 82% 77%
Physician assessment 79% 55% 50%

Holman used simulated gastric specimens and found the Hemoccult test to have significant problems with non-specificy and false-positive results, whereas the Gastroccult test was very accurate [11]. Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on all control samples.

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A note on Bayesian calculations

The predictive values cited are based on the prevalences of upper GI bleeding in the corresponding studies. A clinical calculator can be used to generate predictive values for other prevalences such as those listed above under Prevalences.

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Treatment

Endoscopic image of small gastric ulcer with visible vessel
Endoscopic image of small gastric ulcer with visible vessel

Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions, and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to be administered. Vitals signs are continuously monitored. Image File history File linksMetadata Gastric_ulcer_2. ... Image File history File linksMetadata Gastric_ulcer_2. ... Endoscopic still of esophageal ulcers seen after banding of esophageal varices, at time of esophagogastroduodenosocopy In medicine (gastroenterology), esophagogastroduodenoscopy is a diagnostic endoscopic procedure that visualises the upper part of the gastrointestinal tract up to the duodenum. ... An intravenous drip in a hospital Intravenous therapy or IV therapy is the administration of liquid substances directly into a vein. ... Human blood smear: a - erythrocytes; b - neutrophil; c - eosinophil; d - lymphocyte. ... In medicine (gastroenterology), esophageal varices are extreme dilations of sub mucosal veins in the mucosa of the esophagus in diseases featuring portal hypertension, secondary to cirrhosis primarily. ... Categories: Possible copyright violations ...


Early endoscopy is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the lesion identifies, and can include: Endoscopic still of esophageal ulcers seen after banding of esophageal varices, at time of esophagogastroduodenosocopy In medicine (gastroenterology), esophagogastroduodenoscopy is a diagnostic endoscopic procedure that visualises the upper part of the gastrointestinal tract up to the duodenum. ...

Stigmata of high risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding. An injection is a method of putting liquid into the body with a hollow needle and a syringe which is pierced through the skin long enough for the material to be forced into the body. ... Epinephrine (INN) or adrenaline (BAN) is a hormone and a neurotransmitter. ... Sclerotherapy is a procedure used to treat malformations of blood vessels (vascular malformations) and also those of the lymphatic system, which are vessels involved in the immune system, which provides protection against infection. ... In medicine (gastroenterology), esophageal varices are extreme dilations of sub mucosal veins in the mucosa of the esophagus in diseases featuring portal hypertension, secondary to cirrhosis primarily. ...

Same ulcer seen after endoscopic clipping
Same ulcer seen after endoscopic clipping

Pharmacotherapy includes the following: Image File history File linksMetadata GU_with_clip. ... Image File history File linksMetadata GU_with_clip. ...

  • Proton pump inhibitors (PPIs), which reduce gastric acid production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage. These can be administered orally or intravenously as an infusion depending on the risk of rebleeding.
  • Octreotide is a somatostatin analog believed to shunt blood away from the splanchnic circulation. It has found to be a useful adjunct in management of both variceal and non-variceal upper GI hemorrhage. It is the somatostatin analog most commonly used in North America.
  • Terlipressin is a somatostatin analog most commonly used in Europe for variceal upper GI hemorrhage.
  • Antibiotics are prescribed in upper GI bleeds associated with portal hypertension

If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested. Proton pump inhibitors are a group of drugs whose main action is pronounced and long-lasting reduction of gastric acid production. ... Gastric acid is, together with several enzymes and the intrinsic factor, one of the main secretions of the stomach. ... Somatostatin is a hormone. ... Somatostatin is a hormone. ... Terlipressin as vasoactive drug used for the management of hypotension. ... Somatostatin is a hormone. ... In medicine, portal hypertension is hypertension (high blood pressure) in the portal vein and its branches. ... Binomial name Helicobacter pylori ((Marshall 1985) Goodwin 1989) Helicobacter pylori is a bacterium that infects the mucus lining of the human stomach. ...

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Refractory bleeding

Refractory cases of upper GI hemorrhage may require:

Certain causes of upper GI hemorrhage (including gastric ulcers require repeat endoscopy after the episode of bleeding to ascertain healing of the causative lesion. Endoscopic images of a duodenal ulcer Endoscopy means looking inside and refers to looking inside the human body for medical reasons. ... Tranexamic acid (commonly marketed as Cyclokapron) is often prescribed for excessive bleeding. ... Angiography or arteriography is a medical imaging technique in which an X-ray picture is taken to visualize the inner opening of blood filled structures, including arteries, veins and the heart chambers. ... Factor VII (old name proconvertin) is one of the central proteins in the coagulation cascade. ... A Sengstaken-Blakemore tube in original packaging Balloon tamponade refers to the use of mercury weighted balloons instilled into typically the esophagus or stomach, and inflated to stop refractory bleeding from vascular structures -- including esophageal varices and gastric varices -- in the upper gastrointestinal tract. ... Intraoperative X-Ray of a Humerus fixated by Kirschner wires Surgery (from the Greek meaning hand work) is the medical specialty that treats diseases or injuries by operative manual and instrumental treatment. ... Endoscopic images of a duodenal ulcer Endoscopy means looking inside and refers to looking inside the human body for medical reasons. ...

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References

  1.   Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M. ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis. Am J Emerg Med. 2006 May;24(3):280-5. PMID 16635697 full text
  2.   Ernst AA, Haynes ML, Nick TG, Weiss SJ. Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding. Am J Emerg Med. 1999 Jan;17(1):70-2. PMID 9928705 full text
  3.   Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M. Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis. Ann Emerg Med. 2004 Apr;43(4):525-32. PMID 15039700 full text
  4.   Cuellar RE, Gavaler JS, Alexander JA, Brouillette DE, Chien MC, Yoo YK, Rabinovitz M, Stone BG, Van Thiel DH. Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate. Arch Intern Med. 1990 Jul;150(7):1381-4. PMID 2196022
  5.   Rosenthal P, Thompson J, Singh M. Detection of occult blood in gastric juice. J Clin Gastroenterol. 1984 Apr;6(2):119-21. PMID 6715849
  6.   Holman JS, Shwed JA. Influence of sucralfate on the detection of occult blood in simulated gastric fluid by two screening tests. Clin Pharm. 1992 Jul;11(7):625-7. PMID 1617913
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See also

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Lower gastrointestinal bleeding refers to any form of bleeding in the Lower gastrointestinal tract. ...

External links


  Results from FactBites:
 
BioMed Central | Full text | Risk of upper gastrointestinal bleeding and perforation associated with low-dose aspirin ... (4401 words)
Upper gastrointestinal complications (UGIC) are the major risk associated with aspirin use [1,2,3,4].
Among bleeding cases, the lesion was located at the stomach in 764 (42%) and the duodenum in 811 (44%), remaining unspecified in 258 (14%); 4.1% of bleeding cases were fatal.
Two hundred eighty seven cases (13.6%) of upper gastrointestinal bleeding (n= 248; 13.5%) or perforation (n= 39; 14.3%) were current users of aspirin, as compared to 837 current users among controls (7.3%) yielding to an adjusted RR of 2.0 (95% CI: 1.7-2.3) for all cases (table 2).
Upper Gastrointestinal Endoscopy (2140 words)
An upper gastrointestinal (UGI) endoscopy is a procedure that allows your doctor to look at the interior lining of your esophagus, your stomach, and the first part of your small intestine (duodenum) through a thin, flexible viewing instrument called an endoscope.
Diagnose an infection of the esophagus caused by bacteria, fungi, or viruses.
Bleeding caused by inflammation, an ulcer, a tumor, a tear in the esophagus, or dilated veins (esophageal varices) is present.
  More results at FactBites »

 
 

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