Upper gastrointestinal bleeding

Source: Wikipedia, the free encyclopedia.
Upper gastrointestinal bleeding
Other namesUpper gastrointestinal hemorrhage, gastrorrhagia, upper GI bleed, UGI bleed
duodenal ulcer with a clean base, which is a common cause of upper gastrointestinal hemorrhage.
SpecialtyGastroenterology
SymptomsHematemesis (vomiting blood), coffee ground vomiting, melena, hematochezia (maroon-coloured stool) in severe cases

Upper gastrointestinal bleeding is

vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock
.

Upper gastrointestinal bleeding can be caused by

gastric cancer. The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine the hemoglobin
.

Significant upper gastrointestinal bleeding is considered a

Proton pump inhibitors are often used.[2] Tranexamic acid may also be useful.[2] Procedures (such as TIPS for variceal bleeding) may be used. Recurrent or refractory bleeding may lead to need for surgery
, although this has become uncommon as a result of improved endoscopic and medical treatment.

Upper gastrointestinal bleeding affects around 50 to 150 people per 100,000 a year. It represents over 50% of cases of gastrointestinal bleeding.[2] A 1995 UK study found an estimated mortality risk of 11% in those admitted to hospital for gastrointestinal bleeding.[3]

Signs and symptoms

Persons with upper gastrointestinal bleeding often present with

fatigue and shortness of breath.[citation needed
]

The physical examination performed by the physician concentrates on the following things:[citation needed]

Laboratory findings include

BUN-to-creatinine ratio
.

Causes

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

A number of medications increase the risk of bleeding including

SSRIs double the rate of upper gastrointestinal bleeding.[4]

There are many causes for upper gastrointestinal hemorrhage. Causes are usually anatomically divided into their location in the upper gastrointestinal tract.[citation needed]

People are usually stratified into having either variceal or non-variceal sources of upper gastrointestinal hemorrhage, as the two have different treatment algorithms and prognosis.[citation needed]

The causes for upper gastrointestinal hemorrhage include the following:

Diagnosis

gastric ulcer
with visible vessel

Diagnostic testing

The strongest predictors of an upper gastrointestinal bleed are black stool, age <50 years, and blood urea nitrogen/creatinine ratio 30 or more.[8][9] The diagnosis of upper gastrointestinal bleeding is assumed when hematemesis (vomiting of blood) is observed.[citation needed]

A

ligament of Treitz.[8] A positive aspirate is more helpful than a negative aspirate (If the aspirate is positive, an upper gastrointestinal bleed is likely; if the aspirate is negative, the source of a gastrointestinal bleed is probably, but not certainly, lower). A smaller study found a sensitivity of 79% and specificity of 55%, somewhat opposite results from Witting.[10] The accuracy of the aspirate is improved by using the Gastroccult test.[citation needed
]

Determining whether blood is in gastric contents, either vomited or aspirated specimens, may be a challenge when determining the source of the hemorrhage. Slide tests are based on

orthotolidine (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). There is some evidence that orthotolidine-based tests more sensitive than specific, the Hemoccult test's sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate.[11] The sensitivity, specificity, positive predictive value, and negative predictive value have been reported as follows:[10]

Determining whether blood is in the gastric aspirate[10]
Finding Sensitivity Specificity Positive predictive value
(prevalence of 39%)		 Negative predictive value
(prevalence of 39%)
Gastroccult 95% 82% 77% 96%
Physician assessment 79% 55% 53% 20%

Holman used simulated gastric specimens and found the Hemoccult test to have significant problems with non-specificity and false-positive results, whereas the Gastroccult test was very accurate.[12] Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on all control samples.

A scoring system called the

Glasgow-Blatchford bleeding score found 16% of people presenting with upper gastrointestinal bleed had Glasgow-Blatchford score of "0", considered low. Among these people there were no deaths or interventions needed and they were able to be effectively treated in an outpatient setting.[13]
[14]

Score is equal to "0" if the following are all present:

  1. Hemoglobin level >12.9 g/dL (men) or >11.9 g/dL (women)
  2. Systolic blood pressure >109 mm Hg
  3. Pulse <100/minute
  4. Blood urea nitrogen level <18.2 mg/dL
  5. No melena or syncope
  6. No past or present liver disease or heart failure

Bayesian calculation

The predictive values cited are based on the prevalences of upper gastrointestinal bleeding in the corresponding studies. A clinical calculator can be used to generate predictive values for other prevalences.[citation needed]

Treatment

The initial focus is on

Glasgow Blatchford score less than 2 may not require admission to hospital.[17]

Peptic ulcers

Based on evidence from people with other health problems

crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding.[15] In people with a confirmed peptic ulcer, proton pump inhibitors do not reduce death rates, later bleeding events, or need for surgery.[18] They may decrease signs of bleeding at endoscopy however.[18] In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance.[16] Tranexamic acid might be effective to reduce mortality, but the evidence for this is weak.[15][19] But the evidence is promising.[20] Somatostatin and octreotide while recommended for variceal bleeding have not been found to be of general use for non-variceal bleeds.[15]

Variceal bleeding

For initial fluid replacement colloids or

Minnesota tube may be used in an attempt to mechanically compress the varices.[21] This may then be followed by a transjugular intrahepatic portosystemic shunt.[21]

Blood products

If large amounts of pack red blood cells are used additional

prothrombin complex may decrease mortality.[15]

Procedures

The above ulcer seen after endoscopic clipping

Upper endoscopy within 24 hours is the recommended treatment.

nasogastric tube in those with upper gastrointestinal bleeding are not well known.[15] Prokinetic agents to empty thee stomach such as erythromycin before endoscopy can decrease the amount of blood in the stomach and thus improve the operators view.[15] This erythromycin treatment may lead to a small decrease in the need for a blood transfusion, but the overall balance of how effective erythromycin is compared to potential risks is not clear.[15][23] Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found.[15] It is also recommended that people with high risk signs are kept in hospital for at least 72 hours.[15]
Blood transfusions are not generally recommended to correct anemia, but blood transfusions are recommended if the person is not stable (cardiovascular system instability).
Parenteral Iron is increasingly used in these cases to improve patient outcomes and void blood usage.[citation needed
]

Prognosis

Depending on its severity, upper gastrointestinal bleeding may carry an estimated mortality risk of 11%.[3] However, survival has improved to about 2 percent, likely as a result of improvements in medical therapy and endoscopic control of bleeding.[24]

Epidemiology

About 75% of people presenting to the emergency department with gastrointestinal bleeding have an upper source.[9] The diagnosis is easier when the people have hematemesis. In the absence of hematemesis, 40% to 50% of people in the emergency department with gastrointestinal bleeding have an upper source.[8][10][25]

See also

References

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  2. ^
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  3. ^
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  4. ^ "Are SSRIs associated with upper gastrointestinal bleeding in adults?". Global Family Doctor. Archived from the original on 2011-07-11. Retrieved 2010-11-24.
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  10. ^
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  14. ^ "Glasgow-Blatchford bleeding score". Retrieved 2009-01-24.
  15. ^
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  16. ^
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  17. PMID 31634917
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  18. ^
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  19. PMID 25414987
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  20. S2CID 24594884.{{cite journal}}: CS1 maint: multiple names: authors list (link
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  21. ^
    PMID 20691388
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  22. ^
    PMID 23281973
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  23. ^
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  24. S2CID 49377957
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  25. PMID 15039700.{{cite journal}}: CS1 maint: multiple names: authors list (link
    )

External links
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