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ARTICLES IN THE BOOK

  1. Acute abdomen
  2. Acute coronary syndrome
  3. Acute pancreatitis
  4. Acute renal failure
  5. Agonal respiration
  6. Air embolism
  7. Ambulance
  8. Amnesic shellfish poisoning
  9. Anaphylaxis
  10. Angioedema
  11. Aortic dissection
  12. Appendicitis
  13. Artificial respiration
  14. Asphyxia
  15. Asystole
  16. Autonomic dysreflexia
  17. Bacterial meningitis
  18. Barotrauma
  19. Blast injury
  20. Bleeding
  21. Bowel obstruction
  22. Burn
  23. Carbon monoxide poisoning
  24. Cardiac arrest
  25. Cardiac arrhythmia
  26. Cardiac tamponade
  27. Cardiogenic shock
  28. Cardiopulmonary arrest
  29. Cardiopulmonary resuscitation
  30. Catamenial pneumothorax
  31. Cerebral hemorrhage
  32. Chemical burn
  33. Choking
  34. Chronic pancreatitis
  35. Cincinnati Stroke Scale
  36. Clinical depression
  37. Cord prolapse
  38. Decompression sickness
  39. Dental emergency
  40. Diabetic coma
  41. Diabetic ketoacidosis
  42. Distributive shock
  43. Drowning
  44. Drug overdose
  45. Eclampsia
  46. Ectopic pregnancy
  47. Electric shock
  48. Emergency medical services
  49. Emergency medical technician
  50. Emergency medicine
  51. Emergency room
  52. Emergency telephone number
  53. Epiglottitis
  54. Epilepsia partialis continua
  55. Frostbite
  56. Gastrointestinal perforation
  57. Gynecologic hemorrhage
  58. Heat syncope
  59. HELLP syndrome
  60. Hereditary pancreatitis
  61. Hospital
  62. Hydrocephalus
  63. Hypercapnia
  64. Hyperemesis gravidarum
  65. Hyperkalemia
  66. Hypertensive emergency
  67. Hyperthermia
  68. Hypoglycemia
  69. Hypothermia
  70. Hypovolemia
  71. Internal bleeding
  72. Ketoacidosis
  73. Lactic acidosis
  74. Lethal dose
  75. List of medical emergencies
  76. Malaria
  77. Malignant hypertension
  78. Medical emergency
  79. Meningitis
  80. Neuroglycopenia
  81. Neuroleptic malignant syndrome
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  83. Obstetrical hemorrhage
  84. Outdoor Emergency Care
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  86. Paralytic shellfish poisoning
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  103. Septic shock
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  105. Shock
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  107. Soy allergy
  108. Spinal cord compression
  109. Status epilepticus
  110. Stroke
  111. Temporal arteritis
  112. Testicular torsion
  113. Toxic epidermal necrolysis
  114. Toxidrome
  115. Triage
  116. Triage tag
  117. Upper gastrointestinal bleeding
  118. Uterine rupture
  119. Ventricular fibrillation
  120. Walking wounded
  121. Watershed stroke
  122. Wilderness first aid
  123. Wound
 



THE BOOK OF MEDICAL EMERGENCIES
This article is from:
http://en.wikipedia.org/wiki/Upper_gastrointestinal_bleeding

All text is available under the terms of the GNU Free Documentation License: http://en.wikipedia.org/wiki/Wikipedia:Text_of_the_GNU_Free_Documentation_License 

Upper gastrointestinal bleeding

From Wikipedia, the free encyclopedia

 
Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper GI hemorrhage.
Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper GI hemorrhage.

Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the splenic flexure of the colon.

Upper GI bleeds are considered medical emergencies, and require admission to hospital for urgent diagnosis and management. Due to advances in medications and endoscopy, upper GI hemorrhage is now usually treated without surgery.

Clinical presentation

Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, maroon stool, or hematochezia if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage.

Patients may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath.

The physical examination performed by the physician concentrates on the following things:

  • Vital signs, in order to determine the severity of bleeding and the timing of intervention
  • Abdominal and rectal examination, in order to determine possible causes of hemorrhage
  • Assessment for portal hypertension and stigmata of chronic liver disease in order to determine if the bleeding is from a variceal source.

Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.

Causes

There are many causes for upper GI hemorrhage. Causes are usually anatomically divided into their location in the upper gastrointestinal tract.

Patients are usually stratified into having either variceal or non-variceal sources of upper GI hemorrhage, as the two have different treatment algorithms and prognosis.

Gastric ulcer in antrum of stomach with overlying clot.  Pathology was consistent with gastric lymphoma.  Reproduced with permission of patient
Gastric ulcer in antrum of stomach with overlying clot. Pathology was consistent with gastric lymphoma. Reproduced with permission of patient

The causes for upper GI hemorrhage include the following:

  • Esophageal causes:
    • Esophageal varices
    • Esophagitis
    • Esophageal cancer
    • Esophageal ulcers
  • Gastric causes:
    • Gastric ulcer
    • Gastric cancer
    • Gastritis
    • Gastric varices
    • Gastric antral vascular ectasia, or watermelon stomach
    • Dieulafoy's lesions
  • Duodenal causes:
    • Duodenal ulcer
    • Vascular malformations, including aorto-enteric fistulae
    • Hematobilia, or bleeding from the biliary tree
    • Hemosuccus pancreaticus, or bleeding from the pancreatic duct

Diagnosis

Summary

The diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more. In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using the Gastroccult test.

Details

Prevalence of upper GI bleeding

About 75% of patients presenting to the emergency room with GI bleeding have an upper source 1. The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of patients in the emergency room with GI bleeding have an upper source2 3 4. Determining whether a patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult.

Diagnostic testing

Whiting studied a cohort of 325 patients and found the odds ratios for the strongest predictors were: black stool, 16.6 (95% confidence interval [CI], 7.7-35.7); age < 50 years, 8.4 (95% CI, 3.2-22.1); and blood urea nitrogen/creatinine ratio 30 or more, 10.0 (95% CI, 4.0-25.6)2 . Seven (5%) of 151 with none of these factors had an upper GI tract bleed, versus 63 (93%) of 68 with 2 or 3 factors. Ernst found similar results1.

The nasogastric aspirate can help determine the location of bleeding and thus direct initial diagnostic and treatment plans. Witting found that nasogastric aspirate has sensitivity 42%, specificity 91%, negative predictive value 64%, positive predictive value 92% and overall accuracy of 66% in differentiating upper GI bleeding from bleeding distal to the ligament of Treitz3. Thus, in this study a positive aspirate is more helpful than a negative aspirate. In a smaller study, Cuellar found a sensitivity of 79% and specificity of 55%4, somewhat opposite results from Witting. Cuellar also studied the appearance of the aspirate and a summary of these results is available at the Evidence-Based On-Call database. Although the website lists these results as expired, they were available as of Oct, 16, 2006. These results are also available through the Wayback Archive and readers may consult the Archive if the original page is removed.

Determining whether blood is in gastric contents, either vomited or aspirated specimens, is surprisingly difficult. Slide tests are based on orthotolidine (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). Rosenthal found orthotolidine-based tests more sensitive than specific; the Hemoccult test's sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate5. Cuellar found the following results:

Holman used simulated gastric specimens and found the Hemoccult test to have significant problems with non-specificy and false-positive results, whereas the Gastroccult test was very accurate6. Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on all control samples.

A note on Bayesian calculations

The predictive values cited are based on the prevalences of upper GI bleeding in the corresponding studies. A clinical calculator can be used to generate predictive values for other prevalences such as those listed above under Prevalences.

Treatment

Endoscopic image of small gastric ulcer with visible vessel
Endoscopic image of small gastric ulcer with visible vessel

Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions, and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to be administered. Vitals signs are continuously monitored.

Early endoscopy is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the lesion identifies, and can include:

  • injection of adrenaline or other sclerotherapy
  • electrocautery
  • endoscopic clipping
  • or banding of varices

Stigmata of high risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding.

Same ulcer seen after endoscopic clipping
Same ulcer seen after endoscopic clipping

Pharmacotherapy includes the following:

  • Proton pump inhibitors (PPIs), which reduce gastric acid production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage. These can be administered orally or intravenously as an infusion depending on the risk of rebleeding.
  • Octreotide is a somatostatin analog believed to shunt blood away from the splanchnic circulation. It has found to be a useful adjunct in management of both variceal and non-variceal upper GI hemorrhage. It is the somatostatin analog most commonly used in North America.
  • Terlipressin is a somatostatin analog most commonly used in Europe for variceal upper GI hemorrhage.
  • Antibiotics are prescribed in upper GI bleeds associated with portal hypertension

If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested.

Refractory bleeding

Refractory cases of upper GI hemorrhage may require:

  • Repeat esophagogastroduodenoscopy
  • Anti-fibrinolytics, such as tranexamic acid
  • Angiography to identify and possibly occlude the feeder vessel
  • Recombinant Factor VII is sometimes used as an adjunct in refractory bleeding, but its utility has only been tested for variceal hemorrhage
  • Balloon tamponade
  • Surgery, to oversew or remove the area of hemorrhage

Certain causes of upper GI hemorrhage (including gastric ulcers require repeat endoscopy after the episode of bleeding to ascertain healing of the causative lesion.

References

  • Note 1: Ernst AA, Haynes ML, Nick TG, Weiss SJ. Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding. Am J Emerg Med. 1999 Jan;17(1):70-2. PMID 9928705 full text
  • Note 2: Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M. ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis. Am J Emerg Med. 2006 May;24(3):280-5. PMID 16635697 full text
  • Note 3: Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M. Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis. Ann Emerg Med. 2004 Apr;43(4):525-32. PMID 15039700 full text
  • Note 4: Cuellar RE, Gavaler JS, Alexander JA, Brouillette DE, Chien MC, Yoo YK, Rabinovitz M, Stone BG, Van Thiel DH. Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate. Arch Intern Med. 1990 Jul;150(7):1381-4. PMID 2196022
  • Note 5: Rosenthal P, Thompson J, Singh M. Detection of occult blood in gastric juice. J Clin Gastroenterol. 1984 Apr;6(2):119-21. PMID 6715849
  • Note 6: Holman JS, Shwed JA. Influence of sucralfate on the detection of occult blood in simulated gastric fluid by two screening tests. Clin Pharm. 1992 Jul;11(7):625-7. PMID 1617913

See also

  • Lower gastrointestinal bleeding

External links

  • eMedicine
  • FP Notebook
  • Patient.uk
  • NIH/Medline
Retrieved from "http://en.wikipedia.org/wiki/Upper_gastrointestinal_bleeding"

 

 

 


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