Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding refers to hemorrhage originating proximal to the ligament of Treitz, including the esophagus, stomach, and duodenum. It is a medical emergency with the potential for significant morbidity and mortality.

Epidemiology

• Incidence: ~0.1% of the general population annually.
• UGIB is approximately four times more common than lower GI bleeding.
• Despite advances in endoscopic and medical therapy, 3–15% of patients may still require surgical intervention.

Etiology and Differential Diagnosis

Common Causes

1. Peptic ulcer disease (gastric and duodenal)
2. Esophageal or gastric varices (often due to portal hypertension)
3. Mallory-Weiss tears
4. Esophagitis, erosive gastritis
5. Upper GI malignancies (e.g., gastric or esophageal cancer)
6. Dieulafoy lesions
7. Vascular malformations (e.g., angiodysplasia)
8. Aortoenteric fistula (rare but fatal)
9. Hemobilia or pancreatic sources (pseudoaneurysm)

Risk Factors

• NSAID use
• H. pylori infection
• Alcohol abuse
• Cirrhosis or portal hypertension
• Previous history of ulcers or GI bleeding
• Coagulopathies

Clinical Presentation

Classic Symptoms

• Melena (black tarry stool): 70–80%
• Hematemesis (vomiting of blood): 40–50%
• Hematochezia (bright red blood per rectum): suggests brisk bleeding
• Presyncope/Syncope in hemodynamically unstable patients

Associated Symptoms (preceding days)

• Dyspepsia, epigastric pain, heartburn
• Dysphagia
• Weight loss
• Jaundice (in hepatic etiology)

Initial Assessment & Resuscitation (ABCs)

1. Airway: Secure airway early if risk of aspiration exists.
2. Breathing & Circulation:
   • 2 large-bore IV lines
   • Fluid resuscitation: 3:1 rule (3 mL crystalloid for every 1 mL blood loss)
   • Monitor vital signs: HR <120 bpm, SBP >90 mmHg
   • Insert Foley catheter: Monitor urine output (>30 mL/hr)
   • Continuous monitoring: CVP, O₂ sat, BP, and mental status

Diagnostic Evaluation

Nasogastric Tube Lavage

• Helps differentiate upper vs lower GI bleeding.
• Presence of bile without blood suggests a non-upper source.

Endoscopy (Esophagogastroduodenoscopy, EGD)

• First-line diagnostic and therapeutic tool.
• Ideally performed within 24 hours, or emergently if unstable.
• Allows localization and immediate intervention.

Endoscopic Hemostatic Techniques

1. Injection therapy:
   • Epinephrine (1:10,000 dilution): vasoconstriction & tamponade
   • Saline: tamponade effect alone
2. Sclerosants:
   • Absolute ethanol, polidocanol, sodium tetradecyl sulfate
   • Induce thrombosis, inflammation, and necrosis
3. Thermal coagulation:
   • Bipolar/multipolar electrocoagulation, heater probe, argon plasma coagulator
4. Mechanical:
   • Band ligation (especially for varices)
   • Hemostatic clips
5. Topical agents:
   • Biological glues (e.g., fibrin sealants)
   • Hemostatic powders

Pharmacologic Therapy

• IV Proton Pump Inhibitors (PPIs):
  • Omeprazole, pantoprazole
  • Decreases rebleeding risk in ulcers
• Vasoactive agents for varices:
  • Octreotide or terlipressin

Surgical Indications

Surgery is considered when:

1. Massive or persistent bleeding despite endoscopic and pharmacologic therapy
2. Hemodynamic instability not responsive to resuscitation
3. Bleeding with signs of perforation, obstruction, or suspected malignancy
4. Ongoing transfusion needs or blood loss >50% of blood volume
5. Recurrent bleeding requiring second hospitalization

Surgical Options

Duodenal Ulcers

• Truncal vagotomy + pyloroplasty + suture ligation

• Truncal vagotomy + antrectomy

• Highly selective vagotomy + duodenostomy

Gastric Ulcers

• Often treated with distal gastrectomy (including ulcer)

Options include:

1. Truncal vagotomy + pyloroplasty + wedge resection
2. Antrectomy + ulcer excision
3. Distal gastrectomy ± vagotomy
4. Wedge resection alone (select cases)

Complications

• Rebleeding
• Hypovolemic shock
• Perforation
• Multi-organ failure
• Death (mortality rate 5–10%)

Key Points

• Melena = upper GI bleed until proven otherwise
• Hematemesis = almost always upper GI source
• Early endoscopy is the gold standard
• PPIs reduce the risk of rebleeding in ulcers
• Octreotide for variceal bleeding
• ABCs and volume resuscitation are the first priorities
• NSAIDs + H. pylori are the most common causes of PUD-related bleeding

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