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Ulcerative or erosive diseases of the upper gastrointestinal tract that can cause acute upper
gastrointestinal bleeding include peptic ulcer disease, Zollinger-Ellison syndrome, esophagitis,
erosions of the stomach or duodenum, esophageal ulcers, stress-induced ulcers, infectious ulcers
(herpes simplex virus, cytomegalovirus, or Helicobacter pylori), and medication-induced ulcers
(aspirin, NSAIDs, pills).
1. Peptic Ulcer Disease
Mucosal erosions or ulcers develop from an imbalance between aggressive factors and the
protective factors of the mucosa. Aggressive factors that can damage normal mucosal integrity
include hyperacidity, pepsin, bile salts, ischemia, aspirin, and NSAIDs (which decrease the
protective barrier by inhibition of mucosal prostaglandins), and H pylori (in duodenal and gastric
ulcer, although the mechanism is not fully understood). Protective esophageal mechanisms
include esophageal motility (clearance of refluxed acid), salivary secretions (bicarbonate), and
the lower esophageal sphincter (prevents reflux). Gastric mucosal defenses include mucus, rapid
epithelial renewal, and tissue mediators. Acute upper gastrointestinal bleeding occurs when an
erosion or ulcer disrupts an underlying vein or artery.

Abdominal pain, nausea, vomiting, and hematemesis or melena.

Abdominal discomfort is improved with food or antacids.

History of aspirin or NSAID use, history of peptic ulcer disease and upper
gastrointestinal bleeding.

Epigastric tenderness, succussion splash suggestive of outlet obstruction.

General Considerations
Peptic ulcer disease is the most common cause of severe upper gastrointestinal bleeding,
accounting for 3050% of total cases. Bleeding peptic ulcers account for over 100,000 hospital
admissions per year. Approximately 2025% of ulcer patients with acute upper gastrointestinal
bleeding have severe or recurrent bleeding. Their mortality rate is as high as 36%, due mainly to
recurrent or persistent bleeding, surgical complications, or their underlying disease.
Clinical Findings
The symptoms of patients with bleeding ulcers are nonspecific and can range from silent disease
to severe upper abdominal pain. Classically, ulcer pain is described as gnawing or cramping,
lasting up to several hours, and relieved with food or antacids. Symptoms may recur episodically
for a few weeks followed by asymptomatic periods for weeks or months. Other symptoms may
include early satiety, abdominal distention, anorexia, nausea, or vomiting; these symptoms
suggest a mechanical obstruction or altered gastroduodenal motility. Generally, however, only
3040% of patients with severe ulcer hemorrhage have antecedent ulcer symptoms.

Biochemical and hematologic abnormalities seen with upper gastrointestinal bleeding from
peptic ulcer disease are nonspecific and may be seen with any cause of acute bleeding. These
findings include acute anemia (normocytic, normochromic), elevated blood urea nitrogen (BUN)
and creatinine (dehydration and prerenal azotemia), and prolonged bleeding time (due to aspirin
or NSAID ingestion). An elevated serum gastrin level suggests Zollinger-Ellison syndrome.
Endoscopy is the diagnostic method of choice because of high sensitivity and specificity. In
addition, endoscopy can be used to collect biopsy specimens as well as to treat acute upper
gastrointestinal bleeding (see following section, Treatment). Barium x-ray studies are
less accurate and should not be performed during acute bleeding or when perforation is
suspected. Angiography and radionuclide scans are rarely indicated in acute upper
gastrointestinal bleeding, although angiography may be used to control acute bleeding with coil
or Gelfoam embolization.
Differential Diagnosis
Benign peptic ulcer disease related to hyperacidity must be differentiated from ulcers caused by a
malignant process (gastric or esophageal carcinoma), an infectious process, medications, or
ischemia. The clinical history and endoscopic biopsies will help define the underlying cause.
Other causes of upper abdominal discomfort include nonulcer dyspepsia, malignancy,
cholelithiasis, and pancreatitis. However, most of these conditions are not associated with acute
upper gastrointestinal bleeding.
Complications of bleeding peptic ulcer disease include pain, perforation, and obstruction. The
latter are extremely rare in patients with bleeding ulcers. Other complications are related to
endoscopy or therapeutic hemostasis. Complications associated with endoscopy include
respiratory depression from premedication, aspiration, and perforation. Ulcers may enlarge or
become deeper, or bleeding may worsen during or following endoscopic therapy because of
tissue damage by the sclerosant or thermal coagulation.
The immediate treatment of acute upper gastrointestinal bleeding secondary to peptic ulcer
disease includes medical, endoscopic, and surgical interventions. Medical treatments may
decrease the risk of recurrent bleeding after hospital discharge but do not alter the hospital
course. In the case of ulcer hemorrhage with no stigmata or minor stigmata of recent
hemorrhage, there is a very low rebleeding rate on medical therapy (Table 3-5). Early refeeding
of these ulcer patients may be beneficial and may decrease the hospital stay.
Medical treatments include antacids to neutralize gastric acidity, sucralfate, antisecretory therapy
to decrease acid production, thereby accelerating ulcer healing and decreasing the long-term risk
of ulcer recurrence and rebleeding, and prostaglandin analogs. Eradication of H pylori will
decrease the risk of recurrent duodenal ulcer disease and may prevent recurrent bleeding.
In randomized prospective studies, patients with active bleeding or nonbleeding visible vessels
have a better outcome with endoscopic therapy than with medical therapy (Table 3-6). Ulcers
with a clean base or a flat pigmented spot are at low risk of rebleeding and should not be treated
endoscopically. Adherent clots that are not easily removed endoscopically from the ulcer crater,
ie, with irrigation or gentle suctioning, carry a 2030% risk of rebleeding. These clots should
not be routinely treated with endoscopic therapy because randomized studies have not
demonstrated a benefit compared with medical therapy.