UPPER GASTROINTESTINAL BLEEDING

Definition
Upper gastrointestinal bleeding (UGIB) bleeding proximal to the ligament of treitze

Presentation
Hematamesis Melena Hematochezia Occult GI Bleeding Anemia

Common causes
Peptic ulcer Mallory-Weiss syndrome Esophageal varices Hemorrhagic and Erosive gastropathy (gastritis)

Ulcer

Ulcer with a clean base

Ulcer with a visible vessel in a patient with recent hemorrhage

Barium study demonstrating benign duodenal ulcer

Other causes
Erosive duodenitis Neoplasms Aortoenteric fistulas Vascular lesions (hereditary hemorrhagic telangiectasia) Gastric antral vascular ectasia Dieulafoys lesion Hemobilia Hemosuccus pancreaticu

Small-intestinal sources of bleeding

Beyond the reach of the standard upper endoscopy Difficult to diagnose Majority of cases of obscure GIB Most common -vascular ectasias -tumor (e.g., adenocarcinoma, leiomyoma, lymphoma, benign polyps, carcinoid, metastases, and lipoma).

Small-intestinal sources of bleeding

Crohn's disease infection Ischemia vasculitis small-bowel varices Diverticula Meckel's diverticulum duplication cysts intussusception NSAIDs induce small-intestinal erosions and ulcers

Bleeding etiology Mallory-Weiss tear Esophageal ulcer Peptic ulcer Stress gastritis Varices, portal gastropathy Gastric antral vascular ectasia Malignancy Angiodysplasia Aortoenteric fistula

Historical clues Emesis before hematemesis, alcoholism Odynophagia, GERD, esophagotoxic pill ingestion Epigastric/RUQ pain, NSAID or aspirin use Patient in an ICU, gastrointestinal bleeding occurring after admission, respiratory failure, multiorgan failure Alcoholism, cirrhosis Renal failure, cirrhosis Recent involuntary weight loss, dysphagia, cachexia, early satiety Chronic renal failure, hereditary hemorrhagic telangiectasia Known aortic aneurysm, prior abdominal aortic aneurysm repair

History
Mode of bleeding Rate Duration Frequency Co-morbidities Bleeding tendencies Drugs- warfarin, NSAID

Approach to the Patient

Heart rate Blood pressure Hemoglobin falls 72 h Chronic GIB Low hgb Normal bp and hr Low mcv High Red blood cell distribution width

Diagnostics
CBC Fecal occult Upper endoscopy test of choice

Differentiation of upper from lower GIB

Hematamesis Melena blood is in th GI tract for 14h Hyperactive bowel sound Elevated BUN

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