GI Bleeding - Hematemesis

Hematemesis refers to vomiting of clots, fresh blood, or “coffee grounds” and generally represents bleeding from the upper GI tract (i.e., proximal to the ligament of Treitz). May be associated with black, tarry stools (melena). The spectrum of upper GI bleeding varies from occult hemorrhage that presents as anemia to acute, life-threatening hemorrhage resulting in hypotension and shock. Sources of life-threatening upper GI bleeding include peptic ulcer disease, esophageal varices, and Mallory-Weiss tears.

Differential Diagnosis

• Peptic ulcer disease is the most common etiology of upper GI bleeding
  –Increased risk with NSAID, steroid, or alcohol use; smoking, stress (e.g., ICU and trauma patients), or infections (Helicobacter pylori, CMV, herpes simplex virus)
• Nasopharyngeal or oropharyngeal sources of bleeding
• Esophageal etiologies
  –Esophageal varices (common in alcoholics and cirrhotic patients)
  –Erosive esophagitis: Infectious (e.g., Candida, HSV, CMV), corrosive ingestion, or pill-induced
  –Esophageal or gastric carcinoma
  –Esophageal or gastric polyps
• Gastric etiologies
  –Gastric ulcer
  –Gastritis
  –Arteriovenous malformations: Osler-Weber-Rendu syndrome (cutaneous telangectasias, recurrent nosebleeds), idiopathic angiomas, radiation-induced telangectasias, blue rubber bleb nevus syndrome
  –Mallory-Weiss tear secondary to repetitive vomiting
  –Dieulafoy's lesion: Erosion of the mucosa overlying an artery in the stomach causes necrosis of the arterial wall and resultant hemorrhage
  –Gastric varices: Secondary to splenic vein thrombosis
  –Benign or malignant tumors
• Duodenal etiologies
  –Duodenal ulcer
  –Erosion of a pancreatic tumor into the duodenum
  –Aortoenteric fistula: Must be suspected in any patient with a known aortic graft (e.g., prior AAA repair or occlusive aortic disease)
• Systemic etiologies
  –Coagulopathies (e.g., hemophilia)
  –Thrombocytopenia
  –Anticoagulation therapy (e.g., warfarin)
  –Hereditary hemorrhagic telangiectasia
  –Leukemia
  –Connective tissue disease

Workup and Diagnosis

• Evaluate the severity of bleeding (e.g., signs of shock, orthostatic hypotension, decreased hematocrit) and begin immediate resuscitation if necessary

• Identify the source of bleeding
  –Nasogastric tube insertion to verify upper GI bleeding
  –Upper GI endoscopy (EGD) is diagnostic in most cases (identifies the source of bleeding in 90% of patients) and may be therapeutic
  –Angiography (radionuclide or conventional) is indicated for severe bleeds, if endoscopy is not available, or if endoscopy is inconclusive
  –If patient has a known aortic graft (prior aneurysm repair or aortic occlusive disease), a high index of suspicion for an aortoenteric fistula
• Initial labs should include CBC, coagulation workup (PT/PTT/INR, bleeding time, platelet count), glucose, electrolytes, BUN/creatinine, calcium, liver function tests, and toxicology screen (e.g., for alcohol)
  –Elevated BUN/creatinine ratio suggests upper GI bleed
  –Abnormal prothrombin time suggests coagulopathy
  –Serial hemoglobin/hematocrit measurements are necessary as they may be initially high until volume is replaced; then may decrease

• ECG may be indicated to rule out cardiac ischemia secondary to severe anemia, especially in patients with known diabetes and/or coronary heart disease

Treatment

• Ensure adequate airway, breathing, and circulation
• Stabilize and resuscitate patients as necessary
  –Insert two large-bore IV lines
  –Administer IV fluids (Ringer's lactate or normal saline)
  –Type and cross match two units of packed RBCs
  –Correct coagulopathies if present (e.g., fresh frozen plasma, vitamin K, platelets)
  –Consider blood transfusion
• Identify and treat the source of bleeding
  –IV octreotide (vasoconstrictor) infusion
  –Vasopressin for significant variceal bleeding (contraindicated in CAD or CVA patients)
  –Endoscopy with injection of vasoconstrictors (e.g., epinephrine), sclerosing agents, or electrocautery
  –Angiography with visualization of bleeding vessel and subsequent embolization
  –Surgical control of bleeding if all else fails
• H2 blockers or proton pump inhibitors may be started for suspected peptic ulcer disease or gastritis

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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