Upper gastrointestinal bleeding

Definition

Upper gastrointestinal bleeding is bleeding above the ligament of Treitz, i.e. from the esophagus, stomach or duodenum. Gastrointestinal bleeding can be overt or occult; its manifestations depend on the location and rate of bleeding. Variceal and non-variceal bleeding are distinguished.

Classification

Forrest classification (endoscopic appearance of bleeding ulcers, introduced in 1974):

• Ia: spurting bleeding
• Ib: oozing bleeding
• IIa: non-bleeding visible vessel
• IIb: adherent clot
• IIc: pigmented base
• III: clean base

Forrest Ia and Ib are independent risk factors for persistent or recurrent bleeding.

Risk scores:

• Glasgow–Blatchford score (before endoscopy, 0–23 points): hemoglobin, urea, heart rate, systolic blood pressure, comorbidities (liver disease, heart failure) and presenting features (syncope, melaena).
• Rockall score (0–11 points): age, hemodynamic status, comorbidities, endoscopic diagnosis and stigmata of recent hemorrhage; a version without endoscopic items can be used before endoscopy.
• ABC score: age, urea, albumin, creatinine, altered mental status, cirrhosis, disseminated cancer and American Society of Anesthesiologists classification; for upper and lower bleeding.

Aetiopathogenesis

Common causes (share of upper gastrointestinal bleeds):

• Duodenal ulcer (15–29 %) and gastric ulcer (14–16 %); gastric and duodenal ulcers together account for up to 50 %.
• Varices (5–33 %).
• Mallory–Weiss tear (6–15 %).
• Gastric or duodenal erosions (3–15 %) and erosive esophagitis (2–15 %).
• Angiomas (1–5 %), gastrointestinal stromal tumors (1–5 %), arteriovenous malformations (< 5 %), hemobilia.
• Other vascular lesions: Dieulafoy lesion (an abnormally large artery, mainly in the proximal stomach, with possible massive bleeding), gastric antral vascular ectasia ("watermelon stomach"), hereditary hemorrhagic telangiectasia.

Predisposing factors: chronic liver disease, hereditary coagulation disorders and drugs that affect coagulation or platelet function (e.g. NSAIDs, certain SSRI-type antidepressants) or weaken mucosal defences.

Clinical features

• Hematemesis: vomiting of red blood; indicates upper bleeding, usually from an ulcer, vascular lesion or varix.
• Coffee-ground vomitus: dark brown, granular vomitus; bleeding has slowed or stopped, and hemoglobin has been oxidised to brown hematin by gastric acid.
• Melaena: black, tarry stool; usually upper bleeding, but also possible from the small bowel or right colon. About 100–200 ml of blood in the upper gastrointestinal tract is required; melaena may persist for several days after bleeding has stopped.
• Hematochezia: passage of gross blood per rectum; usually lower bleeding, but possible with vigorous upper bleeding and rapid transit.
• Hypovolaemia and shock: syncope, hypotension, pallor, sweating, tachycardia, oliguria; orthostatic hypotension (a fall of > 20 mmHg systolic or 10 mmHg diastolic with a rise in heart rate) often develops after acute loss of more than 2 units of blood.
• Consequences in pre-existing disease: angina or myocardial infarction in ischemic heart disease; hepatic encephalopathy or hepatorenal syndrome in liver disease.
• Clues to the cause: epigastric pain relieved by food (ulcer, although many bleeding ulcers are painless); cirrhosis or stigmata of liver disease (varices); vomiting and retching before bleeding (Mallory–Weiss); dysphagia (esophageal cancer, stricture); loss of weight (tumor).

Diagnosis

• History: quantity and frequency of blood loss, blood with the first vomit or only after non-bloody vomiting, distinction from hemoptysis; previous bleeding, liver disease, bleeding disorders, drugs and alcohol.
• Physical findings: vital signs and signs of shock; signs of bleeding disorders (petechiae, ecchymoses), chronic liver disease and portal hypertension; digital rectal examination (stool color, masses, fissures).
• Laboratory tests: full blood count; with more significant bleeding, coagulation (platelets, prothrombin time/INR, PTT) and liver function tests; blood typing and cross-match if bleeding continues. A blood urea nitrogen to creatinine ratio > 30 suggests an upper source.
• Nasogastric tube: bloody aspirate indicates active upper bleeding; however, up to 15 % of upper bleeds show no blood in the aspirate.
• Upper endoscopy: the central investigation for locating and characterising the bleeding source.
• Barium studies: no role in acute bleeding.
• Angiography: in selected cases of upper and lower bleeding.

Keep learning in the app

Further reading (open access)

1. MSD Manual Professional: Overview of Gastrointestinal Bleeding
2. MSD Manual Professional: Vascular Gastrointestinal Lesions
3. PMC-Volltext: A Review of Risk Scores within Upper Gastrointestinal Bleeding (J Clin Med 2023)
4. StatPearls: Upper Gastrointestinal Bleeding

Cross-references