Upper gastrointestinal hemorrhage (UGIH) describes bleeding arising from a site proximal to the ligament of Treitz [1] [2]. The leading etiology of UGIH is peptic ulcer disease (PUD), which accounts for 60% of cases and is significantly associated with Helicobacter pylori infection [3] [4]. Other potential causes are Mallory-Weiss tear, gastritis, duodenitis, arteriovenous malformations, esophageal varices, and malignancy [2] [3]. Important risk factors are a history of nonsteroidal anti-inflammatory drug (NSAID) use, alcohol abuse, and chronic renal failure [5]. Other risk factors include chronic liver disease, portal hypertension, and use of certain medications.

UGIH is more predominant in men and in advanced ages [3]. Patients typically report signs such as melena, hematochezia, hematemesis, epigastric or generalized abdominal pain, presyncope, and heartburn [6]. In acute hemorrhage, hematemesis and melena are frequent complaints. Other possible manifestations are chest pain, dysphagia, weight loss, jaundice, and syncope [2] [6].

UGIH is associated with significant morbidity and mortality. Moreover, the risk of death is correlated with factors such as older age and the presence of comorbidities [7] [8]. Another complication is rebleeding, which occurs in 15% of patients [9].

In patients with suspected UGIH, rapid triage will allow the clinician to promptly identify and subsequently resuscitate hemodynamically unstable patients [2]. Furthermore, the clinician should elicit the patient's personal history, the list of medications, and risk factors.

Physical exam

Vital signs are used to assess whether the patient is hemodynamically stable or not. Worrisome signs are tachycardia, hypotension (systolic blood pressure < 90 mm Hg), orthostatic hypotension, and findings indicative of poor perfusion such as cool extremities.

Remarkable abdominal exam findings may contain rebound tenderness, guarding, and evidence of chronic liver disease, while a rectal exam may reveal the presence of blood [2].

Laboratory tests

A complete blood count (CBC), which is key to gauge the blood loss, should be obtained every 4 to 6 hours in order to track and follow the trends. Other important tests are incorporated in a complete metabolic panel (CMP), which evaluates renal and liver function, electrolyte levels, and other parameters, while a coagulation profile is obtained to assess possible coagulopathy. Moreover, a type and cross match is required in case a transfusion is warranted [2].

Diagnostic tests

Stabilized patients will undergo upper endoscopy, which is the recommended initial diagnostic study for UGIH [10]. This procedure also allows for endoscopic treatment as well [2]. There may be a role for the use of capsule endoscopy (CE) to identify patients with low-risk lesions [11].

Nasogastric lavage is utilized to help confirm bleeding and allows for visualization and characterization of the contents.

To evaluate for pathologies such as cirrhosis, pancreatitis, and other rare causes of UGIH, imaging modalities such as computed tomography (CT) scan and ultrasonography are useful [12]. Additionally, chest radiography is used to exclude aspiration pneumonia, esophageal perforation, and other manifestations.

In patients with a negative endoscopy and those with bleeding that is refractory to endoscopic treatment, angiography with transcatheter arterial embolization (TAE) should be considered [10].

Other

An electrocardiogram (EKG) is used to rule out acute myocardial infarction, arrhythmias, and other cardiac-related consequences.

Treatment of UGIB depends on the cause and severity of the bleeding. Initial management focuses on stabilizing the patient, which may involve intravenous fluids, blood transfusions, and medications to reduce stomach acid. Endoscopic therapy can be used to control bleeding directly. In some cases, angiographic embolization or surgery may be necessary if endoscopic treatment is unsuccessful. Medications such as proton pump inhibitors (PPIs) are often used to reduce acid production and promote healing.

The prognosis for UGIB varies depending on the underlying cause, the patient's overall health, and the timeliness of treatment. With prompt and appropriate management, many patients recover fully. However, severe bleeding or delayed treatment can lead to complications such as anemia, shock, or even death. Recurrence of bleeding is possible, particularly if the underlying cause is not addressed.

UGIB can result from various conditions. Common causes include peptic ulcers, gastritis, esophageal varices (enlarged veins in the esophagus), and Mallory-Weiss tears (tears in the lining of the esophagus). Less common causes include tumors, vascular malformations, and certain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and anticoagulants.

UGIB is a relatively common condition, with an estimated incidence of 50-150 cases per 100,000 people annually. It is more prevalent in older adults and those with risk factors such as chronic liver disease, use of NSAIDs, or a history of peptic ulcers. Men are slightly more affected than women.

The pathophysiology of UGIB involves damage to the mucosal lining of the upper gastrointestinal tract, leading to bleeding. This can occur due to erosion from stomach acid, increased pressure in blood vessels (as seen in varices), or mechanical injury (such as tears). The body's response to bleeding includes vasoconstriction and clot formation, but significant or persistent bleeding can overwhelm these mechanisms.

Preventing UGIB involves addressing risk factors and underlying conditions. This may include using medications like PPIs to protect the stomach lining, avoiding NSAIDs, managing chronic conditions such as liver disease, and moderating alcohol consumption. Regular medical check-ups can help identify and manage potential risk factors early.

Upper gastrointestinal bleeding is a potentially serious condition characterized by bleeding in the upper digestive tract. It presents with symptoms like vomiting blood and black stools and requires prompt medical evaluation. Diagnosis is primarily through endoscopy, and treatment focuses on stabilizing the patient and addressing the bleeding source. The prognosis is generally good with timely intervention, but prevention through risk factor management is crucial.

If you or someone you know experiences symptoms such as vomiting blood or passing black stools, it is important to seek medical attention immediately. These symptoms can indicate upper gastrointestinal bleeding, a condition that requires prompt evaluation and treatment. Understanding the risk factors and maintaining regular health check-ups can help prevent this condition. Always discuss any concerns or symptoms with your healthcare provider to ensure appropriate care and management.

1. Lirio RA. Management of Upper Gastrointestinal Bleeding in Children: Variceal and Nonvariceal. Gastrointest Endosc Clin N Am. 2016;26(1):63-73.
2. Wilkins T, Khan N, Nabh A, Schade RR. Diagnosis and Management of Upper Gastrointestinal Bleeding. Am Fam Physician. 2012;85(5):469-476.
3. Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1995;90(2):206–210.
4. Sánchez-Delgado J, Gené E, Suárez D, et al. Has H. pylori prevalence in bleeding peptic ulcer been underestimated? A meta-regression. Am J Gastroenterol. 2011;106(3):398–405.
5. Cheung FK, Lau JY. Management of massive peptic ulcer bleeding. Gastroenterol Clin North Am. 2009;38(2):231-243.
6. al-Assi MT, Genta RM, Karttunen TJ, Graham DY. Ulcer site and complications: relation to Helicobacter pylori infection and NSAID use. Endoscopy. 1996;28(2):229-233.
7. Peter DJ, Dougherty JM. Evaluation of the patient with gastrointestinal bleeding: an evidence based approach. Emerg Med Clin North Am. 1999;17(1):239-261.
8. Zimmerman J, Siguencia J, Tsvang E, Beeri R, Arnon R. Predictors of mortality in patients admitted to hospital for acute upper gastrointestinal hemorrhage. Scand J Gastroenterol. 1995;30(4):327–331.
9. van Leerdam ME, Vreeburg EM, Rauws EA, et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterol. 2003;98(7):1494–1499.
10. Schenker MP, Majdalany BS, Funaki BS, et al. ACR Appropriateness Criteria® upper gastrointestinal bleeding. J Am Coll Radiol. 2010;7(11):845-853.
11. Chandran S, Testro A, Urquhart P, et al. Risk stratification of upper GI bleeding with an esophageal capsule. Gastrointest Endosc. Gastrointest Endosc. 2013;77(6):891-898.
12. Frattaroli FM, Casciani E, Spoletini D, et al. Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding. World J Surg. 2009; 33(10):2209-2217.