Upper Gastrointestinal Bleeding

Maria R. Mascarenhas, MBBSJudith Kelsen, MD

Upper Gastrointestinal Bleeding - BASICS

Upper Gastrointestinal Bleeding - description

Vomiting of blood, whether bright red or dark, constitutes upper GI bleeding or hematemesis. This usually indicates bleeding from the GI tract proximal to the ligament of Treitz. The clinician must differentiate upper GI bleeding from hemoptysis (coughing up blood), nose bleeds, and bleeding from the mouth and pharynx. Sometimes, upper GI bleeding can present with melena or the passage of tarry stools.

Upper Gastrointestinal Bleeding - general prevention

• Avoid drugs that are likely to cause bleeding or gastritis, especially in a susceptible patient.
• In patients with chronic GI conditions, optimize therapy and monitoring.
• Correct coagulopathy.
• Prophylactic sclerotherapy or banding is helpful for patients with known variceal bleeding.

Upper Gastrointestinal Bleeding - DIAGNOSIS

• Approach to the patient:
  • General goals:
    • Determine the cause of the bleeding and begin treatment.
    • Place NG tube and lavage contents of stomach to determine if bleeding is active, and extent of bleeding.
    • Phase 1: Determine whether the emesis contains blood, such as red food coloring, fruit-flavored drinks and juices, vegetables, and some medicines may resemble blood. A pH-buffered Gastroccult test identifies blood in the vomitus or gastric aspirate.
    • Phase 2: Assess severity of bleeding. Is there a change in vital signs, hematocrit, BPs, capillary filling, pulse?
    • Phase 3: Determine the site of bleeding and begin treatment. Examine airway for bleeding: Epistaxis may contaminate emesis to make it resemble upper GI bleeding. Usually diagnosis requires imaging or endoscopy.
• Hints for screening problem:
  • Bright red blood signifies active bleeding.
  • Darker blood or coffee grounds blood usually means that the blood has had some time to become denatured by gastric acid.
  • The rate of bleeding determines the clinical presentation. The more rapid the rate, the larger the volume of bleeding, leading to a greater drop in hemoglobin and change in pulse and blood pressure. Slower bleeding usually presents with anemia and heme-positive stools.
  • Any significant blood loss will lead to pallor, tachycardia, orthostasis, poor capillary refill, CNS changes (e.g., restlessness, confusion), and hypotension.
    • Hypotension is a late sign and may not be present even with significant blood loss because vasoconstriction maintains blood pressure until decompensation occurs.
  • Initial hemoglobin values may be unreliable because a delay in hemodilution may falsely produce near normal values.
  • Absence of blood in the emesis or in nasogastric lavage fluid does not rule out the upper GI tract as the site of bleeding, because a competent pylorus may mask bleeding from a duodenal site.
    • In some cases of massive upper GI bleeding, the patient may not vomit blood but may pass large, black, tarry, or sticky stools (e.g., melena).

Upper Gastrointestinal Bleeding - signs & symptoms

Upper Gastrointestinal Bleeding - history

• Amount of blood (i.e., drops vs. 1 teaspoon vs. 1 tablespoon) indicates severity of bleeding.
• Presence of blood in emesis indicates bleeding from upper GI tract or swallowed blood. Vomitus may not have blood at all, but patient may have recently ingested foods that might resemble
  • Determine the source of bleeding: Hematemesis from the esophagus, stomach, or duodenum versus hemoptysis versus swallowed blood from the nose, mouth, or pharynx.
• Blood coughed is indicative of hemoptysis.
• Bleeding from the nose—swallowed and then vomited—did not originate in the upper GI tract.
• Prolonged retching before hematemesis suggests a Mallory-Weiss tear.
• History of recent stress (e.g., burns, head trauma, surgery) suggests an ulcer or gastritis.
• History of toxic ingestion may result in an ulcerated esophagus, which can bleed. Ingestion of certain medications such as aspirin (as well as other anti-inflammatory drugs) and steroid therapy can lead to gastritis and ulcers. Ingestion of such drugs in combination with ethanol can lead to gastritis.
• Abdominal pain and vomiting blood suggests esophagitis, gastritis, and peptic ulcers.
• Cracked nipples in a breastfeeding mother may lead to the infant swallowing maternal blood and subsequent hematemesis.
• History of gastroesophageal reflux suggests esophagitis.
• Past history of GI disease:
  • Gastroesophageal reflux, peptic ulcer disease, or previous GI surgery may suggest symptoms are due to recurrence of disease.
• History of jaundice, hepatitis, or liver disease suggests portal hypertension and variceal bleeding.
• Neonatal history of umbilical vein catheterization or infection:
  • Portal vein thrombosis (e.g., sepsis, shock, exchange transfusion, omphalitis, IV catheters) suggests portal hypertension and bleeding varices owing to cavernous transformation of the portal vein.
• Familial history of bleeding diathesis (e.g., von Willebrand disease, hemophilia).

Upper Gastrointestinal Bleeding - physical exam

• Any skin petechiae, ecchymosis, or hemangiomas are evidence of chronic liver disease (e.g., spider angiomata, palmar erythema, jaundice).
• Head, ears, eyes, nose, and throat: Nasopharyngeal source of bleeding:
  • Swallowed blood
• Freckles on buccal mucosa:
  • Osler-Weber-Rendu syndrome; Peutz-Jeghers syndrome
• Oral thrush:
  • Candidal esophagitis
• Oral mucosal lesions:
  • Corrosive ingestions
• Abdomen:
  • Hepatosplenomegaly
  • Ascites
  • Portal hypertension
• Isolated splenomegaly:
  • Cavernous transformation of the portal vein; portal hypertension
• Rectal examination
• Heme-positive stool may or may not be present. If positive, confirms the presence of upper GI bleeding

Upper Gastrointestinal Bleeding - tests

Initial hemoglobin may not be accurate, and hemoglobin should be measured serially.

Upper Gastrointestinal Bleeding - lab

• Gastroccult:
  • If possible, check the red substance for blood. In neonates, may need to check for fetal hemoglobin with the Apt test—a test to identify fetal hemoglobin.
• CBC:
  • If leukopenia, anemia, and thrombocytopenia present, consider chronic liver disease and portal hypertension. If anemia is present with normal erythrocyte indices, there is truly an acute cause for bleeding. If erythrocyte indices indicate iron-deficiency anemia, consider varices or a mucosal lesion (i.e., chronic blood loss).
• Coagulation profile:
  • If PT or PTT are abnormal, consider liver disease or disseminated intravascular coagulation (DIC) with sepsis. If disseminated intravascular coagulation screen is negative, consider liver disease. Make sure, however, that blood sample was not contaminated with heparin.
• Bleeding time:
  • Abnormal in patients with previous history (or family history) of bleeding disorders
• Liver function test results:
  • Abnormal in chronic liver disease

Upper Gastrointestinal Bleeding - imaging

• Barium tests:
  • Not as useful as esophagogastroduodenoscopy (EGD), but can identify a large ulcer. Air-contrast upper GI series is better than regular upper GI test.
• Bleeding scan:
  • Useful in the patient with significant bleeding in whom endoscopy undiagnostic. There are 2 types of scans: Technetium sulfur colloid or tagged erythrocyte. The former detects rapid bleeding, but can miss small bleeds, especially if patient is not bleeding during the scan. The latter can detect small bleeds, especially if intermittent.
• Angiography:
  • Useful in detecting vascular causes for upper GI bleeding; can also be therapeutic (i.e., injection of coils into a vascular malformation may occlude it). Invasiveness and need for specialized training of clinicians are limitations.

Upper Gastrointestinal Bleeding - diag proced-surgery

Upper endoscopy:

• Useful: Diagnosis can be made in 75–90% of patients
• Sclerotherapy/Banding, injection of ulcers, heated probes
• Thermo regulation, argon plasma coagulation

Upper Gastrointestinal Bleeding - differencial diagnosis

• 95% of the causes of upper GI bleeding are due to mucosal abnormalities or esophageal varices.
• Mucosal lesions are more likely to be associated with antecedent occult bleeding.
• In ~80–95% of patients, bleeding stops spontaneously.
• Age of the patient is important.
• Neonatal period:
  • Swallowed maternal blood
  • NEC
  • Dudenal web, antral web
  • Hemorrhagic disease of the newborn
  • Esophagitis
  • Gastritis
  • Stress ulcer
  • Foreign body irritation
  • Vascular malformation
  • Gastrointestinal malformation
• Infancy:
  • Esophagitis/Gastritis
  • Stress ulcer
  • Mallory-Weiss tear
  • Pyloric stenosis
  • Vascular malformation
  • Duplication cysts
  • Metabolic disease
• Preschool age:
  • Esophageal varices
  • Esophagitis/Gastritis/Ulcer
  • Foreign body/bezoar
  • Mallory-Weiss tear
  • Vascular malformation
• School age:
  • Esophageal varices
  • infection
  • Esophagitis/Gastritis/Ulcer
  • Mallory-Weiss tear
  • Inflammatory bowel disease
  • Drugs: NSAIDS, alpha-adrenergics antagonists
  • H pylori
• All ages: Liver failure: Coagulopathy

Upper Gastrointestinal Bleeding - TREATMENT

Upper Gastrointestinal Bleeding - initial stabilization

Initial management of the emergency depends on diagnosis and clinical condition of the patient:

• Stabilize the patient with IV fluids and blood products if necessary.
• Order laboratory tests: Complete blood chemistry, PT or PTT, EGD screen, liver function tests, blood type, and cross-match
• Insert a nasogastric tube and lavage with saline to determine site as well as rate of ongoing bleeding. No need for cold saline
• Monitor patient’s vital signs and hemoglobin as necessary.
• Make appropriate diagnosis and institute appropriate therapy (i.e., EGD, bleeding scans).

Upper Gastrointestinal Bleeding - medication

Disease-specific therapy:

• Peptic ulcer disease:
  • Proton pump inhibitors
  • H2 blockers
  • Sucralfate
  • Prokinetic agents
  • H Pylori eradication
• Esophageal varices:
  • Vasopressin or somatostatin infusion
  • Sclerotherapy or banding
  • Sengstaken-Blakemore tube
  • Portosystemic shunts

Upper Gastrointestinal Bleeding - surgery

• Esophageal varices:
  • Sclerotherapy or banding
  • Sengstaken-Blakemore tube
  • Portosystemic shunts
• If bleeding stops quickly, workup is less emergent.

Upper Gastrointestinal Bleeding - FOLLOW UP

• Monitor hemoglobin in the hospital until patient’s condition is stable.
• Once patient is discharged, monitor patient’s hemoglobin weekly as well as Hemoccult cards until stable.
• More specific follow-up depends on the underlying condition.

Upper Gastrointestinal Bleeding - disposition

Upper Gastrointestinal Bleeding - issues for referral

Immediate referral if bleeding is profuse, if patient is hemodynamically unstable, or if bleeding will not stop. Refer any patient with evidence of chronic iron-deficiency anemia and heme-positive stools.

Upper Gastrointestinal Bleeding - bibliography

1. Ament M. Diagnosis and management of upper gastrointestinal bleeding in the pediatric patient. Pediatr Rev. 1990;12:107–116.
Faubion WA, Perrault J. Gastrointestinal bleeding. In: Walker WA, Durie PR, Hamilton JR, et al., eds. Pediatric Gastrointestinal Disease. Philadelphia: BC Decker; 2000:164–178.
2. Fox VL. Gastrointestinal bleeding in infancy and childhood. Gastroenterol Clin North Am. 2000;29:37–66.
3. Hassal E. Sclerotherapy for extrahepatic nonvariceal upper GI bleeding. Med Clin North Am. 1993;77:973–992.
4. Kato S, Sherman P. What is new related to Helicobacter pylori infection in children and teenager? Arch Pediatric Adolsc Med. 2005;159(5):415–421.
5. Molleston JP, Variceal bleeding in children: J Pediatric Gastroenterol and Nutr. 2003;37:538–545.
6. Sherman PM. Peptic ulcer disease in children—diagnosis, treatment and the implication of Helicobacter pylori. Gastroenterol Clin North Am. 1994;23:707–725.
7. Spoliodoro JV, Kay M. New endoscopic and diagnostic techniques: Working group report of the First World Congress of Pediatric Gastroenterology Hepatology and Nutrition: Management of GI bleeding, dysplasia screening and endoscopic training—issues for the new millennium. J Pediatr Gastroenterol Nutr. 2002;35:S196–S204.
8. Squires RH. Gastrointestinal bleeding. Pediatr Rev. 1999;20:95–101.
9. Vinton NE. Gastrointestinal bleeding in infancy and childhood. Gastroenterol Clin North Am. 1994;23:93–122.

Upper Gastrointestinal Bleeding - CODES

Upper Gastrointestinal Bleeding - icd9

578.9 Hemorrhage, gastrointestinal (tract)

Upper Gastrointestinal Bleeding - FAQ

• Q: When do you refer a patient?
• A: Any bleeding—immediate referral if bleed is large, the patient is hemodynamically unstable, and bleeding will not stop. Patient with evidence of chronic iron-deficiency anemia and heme-positive stools
• Q: What makes upper GI bleeding an emergency?
• A: Any persistent bleed with change in vital signs; significant drop in hemoglobin

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

Other Book Chapters Related to Gastrointestinal bleeding

Read excerpts from these other book chapters related to Gastrointestinal bleeding:

Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

More About Causes of Gastrointestinal bleeding

• Back to symptom: Gastrointestinal bleeding: Introduction (review 199 causes)
• Next Book Extract About Gastrointestinal bleeding: Medications causing Gastrointestinal bleeding
• All Book Extracts: All Online Book Extracts for Gastrointestinal bleeding

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

 » Next page: Medications causing Gastrointestinal bleeding

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Medications causing Gastrointestinal bleeding
• Videos relating to Gastrointestinal bleeding
• Drug interactions causing Gastrointestinal bleeding
• Diagnosis Checklist for Gastrointestinal bleeding
• Types of Gastrointestinal bleeding

Tools & Services:

• Bookmark this page
• Related medical articles for Gastrointestinal bleeding:
• Take a survey relating to Gastrointestinal bleeding
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City