Upper gastrointestinal (GI) bleeding occurs when the inner lining (mucosa) of the esophagus, stomach, or proximal small intestine (duodenum) is injured, exposing the underlying blood vessels, or when the blood vessels themselves rupture. Upper GI bleeding can range in severity from clinically inapparent (insignificant) to large-volume, life-threatening bleeding. A variety of conditions can cause GI bleeding, and effective treatment depends on identification of the source of the bleeding and expeditious administration of therapy. (1)
Non-variceal upper gastrointestinal bleeding can be caused by a variety of conditions. Peptic ulcer is the most common cause (Figure 2). An ulcer bleeds when the blood vessels at the base of the ulcer are disrupted. Ulcers are most likely to occur in the stomach and duodenum and less frequently in the esophagus. Ulcers are caused most commonly by an infection with the bacterium Helicobacter pylori or use of nonsteroidal anti-inflammatory drugs. (See Knol on Peptic Ulcer Disease)
Mallory-Weiss tears are rents that occur in the mucosa of the esophagus and proximal stomach, most commonly as a result of retching or vomiting. However, nearly a quarter of people who present with a Mallory-Weiss tear have no antecedent nausea or vomiting.
Vascular abnormalities of the mucosa can be small (telangiectasias) or large (arteriovenous malformations or AVMs). They are tangles of blood vessels that can occur anywhere in the GI tract and are an infrequent cause of upper GI bleeding. They can appear alone or in association with cirrhosis, kidney disease, or an inherited disease of blood vessels known as hereditary hemorrhagic telangiectasia.
A Dieulafoy lesion is a large, dilated vessel near the inner surface of the stomach or other segments of the GI tract. These vessels can erode and cause large-volume bleeding.
Although an infrequent cause, cancers of the upper GI tract can lead to upper GI bleeding, often in association with other symptoms such as weight loss and loss of appetite. Cancers of the upper GI tract may occur in the esophagus, stomach, and rarely the duodenum. Cancers of other organs that metastasize to the GI tract and some benign tumors may also be sources of upper GI bleeding. These cancers cause bleeding when they erode into blood vessels of the GI tract.
Less common causes of upper GI bleeding include an aortoenteric fistula (a connection between the aorta, the major artery of the body, and usually the duodenum, frequently following surgical repair of an aortic aneurysm), gastric antral vascular ectasia, (a condition characterized by multiple bleeding small blood vessels in the stomach); portal hypertensive gastropathy (congestion of the small blood vessels of the stomach from cirrhosis); hemobilia (bleeding from the gallbladder, liver, or bile ducts into the bile duct, which drains into the duodenum), and hemosuccus pancreaticus (bleeding caused by injury to the pancreas).
Patients with substantial blood loss from upper GI bleeding may have evidence of shock, characterized by a low blood pressure and rapid heart rate. They may appear pale due to anemia. Abdominal pain can accompany upper GI bleeding from ulcers or esophagitis, thereby providing a clue to the cause of bleeding.
Discussion with the patient or the patient’s family may yield helpful clues to the cause of upper GI bleeding. The use of nonsteroidal anti-inflammatory drugs can suggest the presence of a peptic ulcer. A history of heavy alcohol use raises the possibility that the patient has cirrhosis and that bleeding is from esophageal or gastric varices. Recent retching or vomiting points toward a Mallory-Weiss tear, and a history of surgery for an aortic aneurysm may point toward an aortoenteric fistula.
A physical examination can also help determine the cause of bleeding. Frequent determination of the patient’s vital signs, particularly the blood pressure and pulse, is essential for assessing the degree of blood loss and the urgency of measures needed to restore the blood volume. A low blood pressure and/or elevated heart rate necessitates the need for immediate resuscitation with fluid and blood. Dilated blood vessels on the chest or back (spider angiomas) or around the belly button (caput medusa), fluid in the abdomen (ascites), and redness of the palms (palmer erythema) can all indicate cirrhosis and the possibility of bleeding from esophageal or gastric varices. Telangiectasias on the skin suggest the possibility of bleeding telangiectasias in the GI tract.
Laboratory tests are important for evaluating a patient with an upper GI bleed. Anemia (low blood count) is common, although if the bleeding is recent, anemia may not yet be evident. An elevated blood urea nitrogen level reflects the absorption of blood by the small intestine as well as dehydration and is characteristic of upper GI bleeding. If H. pylori-induced ulcer disease is suspected, a blood test for H. pylori can be checked.
In patients with severe GI bleeding, nasogastric (NG) lavage is often performed to determine the approximate location and severity of bleeding. A tube is inserted via the nose through the esophagus and into the stomach. A saline solution is instilled via the tube into the stomach and then withdrawn. Withdrawal of fluid that appears bloody indicates ongoing bleeding in the esophagus or stomach. However, a negative NG lavage (withdrawal of nonbloody fluid) does not exclude an upper GI source of bleeding, as the bleeding site may be beyond the reach of the tube or bleeding may have ceased.
After the patient’s blood volume is restored, upper endoscopy is usually performed. Upper endoscopy is a procedure in which a scope with a camera on the end is inserted through the mouth into the esophagus, stomach, and proximal small intestine while the patient is under sedation. The camera can transmit images from the inside of the GI tract and identify the source of bleeding. Upper endoscopy is valuable not only for directly visualizing the inside of the upper GI tract, but also for facilitating treatment of the bleeding source, as discussed below.
Medications used in the treatment of upper GI bleeding include proton pump inhibitors (PPIs) or histamine-2 blockers, which can be given intravenously or orally. These medications reduce the amount of acid produced in the stomach and facilitate the healing of ulcers. They also help blood clot, but their benefit in upper GI bleeding not caused by an ulcer or esophagitis is uncertain. If esophageal or gastric variceal bleeding is suspected, octreotide, a medication which decreases the pressure within varices, should be administered intravenously. Additionally, patients with upper GI bleeding in the setting of liver cirrhosis and ascites (fluid in the abdomen) should receive antibiotics to prevent infection of the ascites.
Once stabilized, patients should undergo upper endoscopy to identify and treat the bleeding source. Upper endoscopy is performed under conscious sedation. Conscious sedation involves the use of medications that control pain and anxiety but still allow a patient to breath without the help of a ventilator. Endoscopic methods to arrest bleeding from an ulcer or vascular abnormality include the injection of agents that constrict blood vessels, electrocautery, and application of clips that seal the bleeding vessel.(3, 4) The method used is based on the appearance of the individual lesion and the preference of the endoscopist. Most often a combination of methods is used to treat the bleeding. These measures are highly effective in arresting bleeding, and surgery to stop bleeding is now required infrequently.
For esophageal variceal bleeding a special endoscopic technique called band ligation is used, by which rubber bands are placed on varices to cause constriction and arrest bleeding. (5) The technique is effective at stopping bleeding in 90% of cases. Infrequently, band ligation fails to stop severe bleeding, and a Sengstaken-Blakemore or Minnesota tube is placed via the patient’s mouth into the esophagus and proximal stomach. The device is anchored by a balloon inflated in the stomach, after which a second balloon may be inflated in the esophagus. The balloons compress the varices in the stomach and esophagus, providing tamponade to stop bleeding. However, because of the high pressure applied, the tubes can cause injury to the esophagus and cannot be left in place for more than 24 hours; it is used to stop bleeding long enough so that additional measures, as described below, can be instituted.
A transjugular intrahepatic portosystemic shunt (TIPS) may be placed when esophageal and gastric variceal bleeding cannot be stopped with medications and endoscopic therapy. The TIPS is inserted over a catheter placed via a large vein in the neck and advanced into the liver, where it creates a tunnel that allows blood to pass freely through the scarred liver, thereby decompressing the varices and preventing further bleeding. Unfortunately, because the liver normally acts to filter toxins from the blood, shunting of blood via a TIPS placed in the liver increases the delivery of toxins to the brain and can result in mental confusion known as hepatic encephalopathy. Although, hepatic encephalopathy is usually treatable with medications, TIPS is generally considered a treatment of last resort for bleeding varices because of the high risk of associated complications. Moreover, TIPS frequently become occluded (clogged), and interventions to keep a TIPS patent (fully open) are generally required several times per year. In the past, shunts to bypass the liver and decompress varices were created surgically, but the mortality rate associated with such an operation was high and surgery is now avoided in patients with bleeding varices.
Once bleeding has stopped the focus of care turns toward preventing recurrent bleeding. For a bleeding ulcer, H. pylori, the most common cause of peptic ulcer, should be treated, if present; NSAIDs should be discontinued, and a PPI continued for at least 6-8 weeks. For patients with esophageal varices that have stopped bleeding without the need for a TIPS, a nonselective beta blocker (e.g., nadolol or propranolol), taken orally, is often prescribed to decrease pressure in the liver and the risk of recurrent bleeding. Additionally, endoscopy is repeated at intervals to perform band ligation to eradicate the varices and prevent recurrent bleeding. With these measures the risk of recurrent GI bleeding can be substantially reduced.
While upper GI bleeding can be life threatening, seeking immediate medical care for aggressive resuscitation and medical and endoscopic therapy significantly improve patient outcomes.
Cause
Upper GI bleeding can be divided into two broad categories: variceal bleeding and non-variceal bleeding. Varices are dilated blood vessels found most frequently in the esophagus and stomach (Figure 1). The veins of the esophagus and stomach drain into the portal vein which carries blood into the liver. When the liver is scarred, as in cirrhosis, blood flow through the liver is restricted and blood cannot drain sufficiently from the esophagus and stomach. The resulting congestion leads to high pressure in the veins of the esophagus and stomach, causing them to enlarge. If these veins become very large, they can rupture resulting in high-volume bleeding.Non-variceal upper gastrointestinal bleeding can be caused by a variety of conditions. Peptic ulcer is the most common cause (Figure 2). An ulcer bleeds when the blood vessels at the base of the ulcer are disrupted. Ulcers are most likely to occur in the stomach and duodenum and less frequently in the esophagus. Ulcers are caused most commonly by an infection with the bacterium Helicobacter pylori or use of nonsteroidal anti-inflammatory drugs. (See Knol on Peptic Ulcer Disease)
Mallory-Weiss tears are rents that occur in the mucosa of the esophagus and proximal stomach, most commonly as a result of retching or vomiting. However, nearly a quarter of people who present with a Mallory-Weiss tear have no antecedent nausea or vomiting.
Vascular abnormalities of the mucosa can be small (telangiectasias) or large (arteriovenous malformations or AVMs). They are tangles of blood vessels that can occur anywhere in the GI tract and are an infrequent cause of upper GI bleeding. They can appear alone or in association with cirrhosis, kidney disease, or an inherited disease of blood vessels known as hereditary hemorrhagic telangiectasia.
A Dieulafoy lesion is a large, dilated vessel near the inner surface of the stomach or other segments of the GI tract. These vessels can erode and cause large-volume bleeding.
Although an infrequent cause, cancers of the upper GI tract can lead to upper GI bleeding, often in association with other symptoms such as weight loss and loss of appetite. Cancers of the upper GI tract may occur in the esophagus, stomach, and rarely the duodenum. Cancers of other organs that metastasize to the GI tract and some benign tumors may also be sources of upper GI bleeding. These cancers cause bleeding when they erode into blood vessels of the GI tract.
Less common causes of upper GI bleeding include an aortoenteric fistula (a connection between the aorta, the major artery of the body, and usually the duodenum, frequently following surgical repair of an aortic aneurysm), gastric antral vascular ectasia, (a condition characterized by multiple bleeding small blood vessels in the stomach); portal hypertensive gastropathy (congestion of the small blood vessels of the stomach from cirrhosis); hemobilia (bleeding from the gallbladder, liver, or bile ducts into the bile duct, which drains into the duodenum), and hemosuccus pancreaticus (bleeding caused by injury to the pancreas).
Symptoms and Signs
Patients with upper GI bleeding may present with hematemesis (vomiting blood) or melena (black stool) and may experience substantial blood loss. In patients with upper GI bleeding, blood mixes with stomach acid resulting eventually in black, tarry appearing stool. If bleeding is brisk, however, the stool can appear red or maroon as it exits the rectum, signifying a potentially life-threatening bleed. In contrast, slow or small volume bleeding can result in normal appearing stool with only microscopically detectable blood.Patients with substantial blood loss from upper GI bleeding may have evidence of shock, characterized by a low blood pressure and rapid heart rate. They may appear pale due to anemia. Abdominal pain can accompany upper GI bleeding from ulcers or esophagitis, thereby providing a clue to the cause of bleeding.
Diagnosis
Hospitalization is required for anyone with overt upper GI bleeding. Patients in shock may need to be admitted to the intensive care unit.Discussion with the patient or the patient’s family may yield helpful clues to the cause of upper GI bleeding. The use of nonsteroidal anti-inflammatory drugs can suggest the presence of a peptic ulcer. A history of heavy alcohol use raises the possibility that the patient has cirrhosis and that bleeding is from esophageal or gastric varices. Recent retching or vomiting points toward a Mallory-Weiss tear, and a history of surgery for an aortic aneurysm may point toward an aortoenteric fistula.
A physical examination can also help determine the cause of bleeding. Frequent determination of the patient’s vital signs, particularly the blood pressure and pulse, is essential for assessing the degree of blood loss and the urgency of measures needed to restore the blood volume. A low blood pressure and/or elevated heart rate necessitates the need for immediate resuscitation with fluid and blood. Dilated blood vessels on the chest or back (spider angiomas) or around the belly button (caput medusa), fluid in the abdomen (ascites), and redness of the palms (palmer erythema) can all indicate cirrhosis and the possibility of bleeding from esophageal or gastric varices. Telangiectasias on the skin suggest the possibility of bleeding telangiectasias in the GI tract.
Laboratory tests are important for evaluating a patient with an upper GI bleed. Anemia (low blood count) is common, although if the bleeding is recent, anemia may not yet be evident. An elevated blood urea nitrogen level reflects the absorption of blood by the small intestine as well as dehydration and is characteristic of upper GI bleeding. If H. pylori-induced ulcer disease is suspected, a blood test for H. pylori can be checked.
In patients with severe GI bleeding, nasogastric (NG) lavage is often performed to determine the approximate location and severity of bleeding. A tube is inserted via the nose through the esophagus and into the stomach. A saline solution is instilled via the tube into the stomach and then withdrawn. Withdrawal of fluid that appears bloody indicates ongoing bleeding in the esophagus or stomach. However, a negative NG lavage (withdrawal of nonbloody fluid) does not exclude an upper GI source of bleeding, as the bleeding site may be beyond the reach of the tube or bleeding may have ceased.
After the patient’s blood volume is restored, upper endoscopy is usually performed. Upper endoscopy is a procedure in which a scope with a camera on the end is inserted through the mouth into the esophagus, stomach, and proximal small intestine while the patient is under sedation. The camera can transmit images from the inside of the GI tract and identify the source of bleeding. Upper endoscopy is valuable not only for directly visualizing the inside of the upper GI tract, but also for facilitating treatment of the bleeding source, as discussed below.
Treatment
Initial treatment of any person with an upper GI bleed consists of administration of fluid and blood via intravenous (IV) access to restore and maintain the patient’s vital signs.(2) A patient with severe, ongoing hematemesis may be at risk for aspiration – inhalation of blood and vomitus into the lungs. Such patients may be managed with intubation, by which a breathing tube is placed via the mouth directly into the lungs, to protect the lungs. Patients with severe GI bleeding, multiple medical problems, a low blood pressure, or the need for multiple blood transfusions require care in an intensive care unit, where their vital signs can be monitored closely. If a patient has any evidence of a coagulopathy (blood that clots poorly), fresh frozen plasma may be infused intravenously or vitamin K given by injection to reverse the coagulopathy. Any blood thinning medications that the patient has been taking, such as warfarin, should be discontinued. A difficult issue arises when a patient has had a so-called drug-eluting stent placed in a coronary artery and is taking the medication clopidogrel. Clopidogrel is vital for preventing cardiac stents from developing life-threatening clots but also thins the blood. Before clopidogel is discontinued, even during a major upper GI bleed, a cardiologist should be consulted.Medications used in the treatment of upper GI bleeding include proton pump inhibitors (PPIs) or histamine-2 blockers, which can be given intravenously or orally. These medications reduce the amount of acid produced in the stomach and facilitate the healing of ulcers. They also help blood clot, but their benefit in upper GI bleeding not caused by an ulcer or esophagitis is uncertain. If esophageal or gastric variceal bleeding is suspected, octreotide, a medication which decreases the pressure within varices, should be administered intravenously. Additionally, patients with upper GI bleeding in the setting of liver cirrhosis and ascites (fluid in the abdomen) should receive antibiotics to prevent infection of the ascites.
Once stabilized, patients should undergo upper endoscopy to identify and treat the bleeding source. Upper endoscopy is performed under conscious sedation. Conscious sedation involves the use of medications that control pain and anxiety but still allow a patient to breath without the help of a ventilator. Endoscopic methods to arrest bleeding from an ulcer or vascular abnormality include the injection of agents that constrict blood vessels, electrocautery, and application of clips that seal the bleeding vessel.(3, 4) The method used is based on the appearance of the individual lesion and the preference of the endoscopist. Most often a combination of methods is used to treat the bleeding. These measures are highly effective in arresting bleeding, and surgery to stop bleeding is now required infrequently.
For esophageal variceal bleeding a special endoscopic technique called band ligation is used, by which rubber bands are placed on varices to cause constriction and arrest bleeding. (5) The technique is effective at stopping bleeding in 90% of cases. Infrequently, band ligation fails to stop severe bleeding, and a Sengstaken-Blakemore or Minnesota tube is placed via the patient’s mouth into the esophagus and proximal stomach. The device is anchored by a balloon inflated in the stomach, after which a second balloon may be inflated in the esophagus. The balloons compress the varices in the stomach and esophagus, providing tamponade to stop bleeding. However, because of the high pressure applied, the tubes can cause injury to the esophagus and cannot be left in place for more than 24 hours; it is used to stop bleeding long enough so that additional measures, as described below, can be instituted.
A transjugular intrahepatic portosystemic shunt (TIPS) may be placed when esophageal and gastric variceal bleeding cannot be stopped with medications and endoscopic therapy. The TIPS is inserted over a catheter placed via a large vein in the neck and advanced into the liver, where it creates a tunnel that allows blood to pass freely through the scarred liver, thereby decompressing the varices and preventing further bleeding. Unfortunately, because the liver normally acts to filter toxins from the blood, shunting of blood via a TIPS placed in the liver increases the delivery of toxins to the brain and can result in mental confusion known as hepatic encephalopathy. Although, hepatic encephalopathy is usually treatable with medications, TIPS is generally considered a treatment of last resort for bleeding varices because of the high risk of associated complications. Moreover, TIPS frequently become occluded (clogged), and interventions to keep a TIPS patent (fully open) are generally required several times per year. In the past, shunts to bypass the liver and decompress varices were created surgically, but the mortality rate associated with such an operation was high and surgery is now avoided in patients with bleeding varices.
Once bleeding has stopped the focus of care turns toward preventing recurrent bleeding. For a bleeding ulcer, H. pylori, the most common cause of peptic ulcer, should be treated, if present; NSAIDs should be discontinued, and a PPI continued for at least 6-8 weeks. For patients with esophageal varices that have stopped bleeding without the need for a TIPS, a nonselective beta blocker (e.g., nadolol or propranolol), taken orally, is often prescribed to decrease pressure in the liver and the risk of recurrent bleeding. Additionally, endoscopy is repeated at intervals to perform band ligation to eradicate the varices and prevent recurrent bleeding. With these measures the risk of recurrent GI bleeding can be substantially reduced.
While upper GI bleeding can be life threatening, seeking immediate medical care for aggressive resuscitation and medical and endoscopic therapy significantly improve patient outcomes.
Figure 1: Esophageal varices filling the lumen of the esophagus as seen on upper endoscopy
Figure 2: Gastric ulcer with bleeding vessel (yellow arrow) as seen on upper endoscopy
Figure 3: Gastric erosions (black arrows) caused by ibuprofen as seen on upper endoscopy
References
1. Yachimski PS, Friedman LS. Gastrointestinal bleeding in the elderly. Nat Clin Pract Gastroenterol Hepatol. 2008;5(2):80-93.
2. Rockey DC. Gastrointestinal bleeding. Gastroenterol Clin North Am. 2005;34(4):581-8.
3. Ferguson CB, Mitchell RM. Nonvariceal upper gastrointestinal bleeding: standard and new treatment. Gastroenterol Clin North Am. 2005;34(4):607-21.
4. Martins NB, Wassef W. Upper gastrointestinal bleeding. Curr Opin Gastroenterol. 2006;22(6):612-9.
5. Habib A, Sanyal AJ. Acute variceal hemorrhage. Gastrointest Endosc Clin N Am. 2007;17(2):223-52, v.
scotpics
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BLOGGER UYGHUR
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Polypectomy may also cause bleeding