Acute upper gastrointestinal bleeding
Acute upper gastrointestinal bleeding arises proximal to the ligament of Treitz and presents with hematemesis or melena, most often from peptic ulcer disease or bleeding gastroesophageal varices. Management sequences resuscitation, restrictive transfusion, IV proton pump inhibitor therapy, and, when varices are suspected, octreotide plus antibiotic prophylaxis, all before upper endoscopy within 24 hours, which is both diagnostic and therapeutic.
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What this article covers
- Overview
Definition: acute upper gastrointestinal bleeding (UGIB) is hemorrhage originating proximal to the ligament of Treitz, from the esophagus, stomach, or duodenum.
- Epidemiology
Dominant cause: peptic ulcer disease, about 50% of UGIB, from gastroduodenal ulcers related to Helicobacter pylori or NSAID use.
- Risk factors
Peptic ulcer disease: Helicobacter pylori infection and NSAID use are the leading drivers of ulcer formation and bleeding (peptic ulcer disease).
- Pathophysiology
Ulcer bleeding: Helicobacter pylori or NSAID injury erodes the gastroduodenal mucosa down to a submucosal artery; the endoscopic stigma (active spurting, visible vessel, or adherent clot) determines rebleeding risk.
- Clinical features
Hematemesis: vomiting of bright red blood or coffee-ground material, indicating a source proximal to the ligament of Treitz.
- Differential diagnosis
Peptic ulcer disease: epigastric pain with active bleeding, a nonbleeding visible vessel, or an adherent clot at endoscopy; the leading cause (peptic ulcer disease).
- Diagnosis
Confirmed and localized by upper endoscopy, both diagnostic and therapeutic: endoscopy identifies the bleeding lesion, determines rebleeding risk by its stigmata, and delivers hemostatic therapy in the same procedure.
- Management
Resuscitate first, before endoscopy: establish two large-bore peripheral IV catheters (minimum 18-gauge), start IV crystalloid, and check hemoglobin, platelets, and coagulation studies.
- Complications
Hemorrhagic shock: from ongoing or massive blood loss, the immediate life threat driving resuscitation priorities.
- Prognosis
Outcome tracks the bleeding source and risk score: variceal hemorrhage carries higher mortality than peptic ulcer bleeding, and higher Glasgow-Blatchford and Rockall scores predict greater risk of intervention, rebleeding, and death.
- Prevention
Test for and eradicate Helicobacter pylori in patients with peptic ulcer disease to prevent recurrent ulcer bleeding (peptic ulcer disease).
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Related articles
- Peptic ulcer disease
Peptic ulcer disease is a mucosal break in the stomach or duodenum caused chiefly by Helicobacter pylori infection or NSAID use, diagnosed by upper endoscopy with biopsy of gastric ulcers to exclude malignancy. Treatment eradicates H. pylori when present, stops the ulcerogenic drug, and heals the ulcer with a proton pump inhibitor, while its complications of bleeding, perforation, and obstruction drive most of its morbidity.
- Gastroesophageal varices
Gastroesophageal varices are dilated portosystemic collateral veins that form as portal pressure rises in cirrhosis, and their rupture causes acute variceal hemorrhage, a GI emergency treated with vasoactive therapy, prophylactic antibiotics, and urgent endoscopic band ligation. Screening endoscopy in cirrhotics guides primary prophylaxis with a nonselective beta-blocker or ligation, and survivors of a bleed require combined beta-blocker and serial ligation for secondary prophylaxis.
- Mallory-Weiss syndrome
Mallory-Weiss syndrome is a partial-thickness, longitudinal mucosal tear at the gastroesophageal junction caused by forceful retching or vomiting, classically presenting as hematemesis after an initial bout of non-bloody vomiting in a patient with alcohol use disorder or bulimia. Upper endoscopy is both diagnostic and therapeutic, most tears stop bleeding spontaneously, and active bleeding is controlled endoscopically.
- Acute lower gastrointestinal bleeding
Acute lower gastrointestinal bleeding is hematochezia from a source distal to the ligament of Treitz, most often diverticular, that requires simultaneous resuscitation and localization because a brisk upper source can masquerade as the same presentation. Colonoscopy after rapid bowel preparation is the first-line diagnostic and therapeutic study in stable patients, while CT angiography localizes active bleeding in unstable or rapidly bleeding patients before catheter embolization or surgery.
- Cirrhosis
Cirrhosis is end-stage hepatic fibrosis with regenerative nodules, staged as compensated or decompensated by the onset of ascites, variceal hemorrhage, encephalopathy, or jaundice. Severity is graded by Child-Pugh class and MELD, and management centers on treating the underlying cause, surveillance for varices and hepatocellular carcinoma, and timely transplant referral once decompensation appears.
- Esophagitis
Esophagitis is mucosal inflammation of the esophagus with four principal causes, reflux, pill-induced, infectious, and caustic or radiation injury, each with a distinguishing pattern confirmed by upper endoscopy with biopsy or brushings. Management is cause-directed: acid suppression for reflux, stopping the offending pill with upright water intake, and targeted antimicrobials (fluconazole, acyclovir, or ganciclovir) for the specific infectious organism.