Upper Gastrointestinal Bleeding - Practice Essentials, Background, Etiology

8/26/2015
UpperGastrointestinalBleeding:PracticeEssentials,Background,Etiology
UpperGastrointestinalBleeding
Author:MauriceACerulli,MD,FACP,FACG,FASGE,AGAFChiefEditor:BSAnand,MDmore...
Updated:Dec22,2014
PracticeEssentials
Acutegastrointestinalbleedingisapotentiallylifethreateningabdominal
emergencythatremainsacommoncauseofhospitalization.Uppergastrointestinal
bleeding(UGIB)isdefinedasbleedingderivedfromasourceproximaltothe
ligamentofTreitz.
Theimagebelowdepictsanulcerwithactivebleeding.
Ulcerwithactivebleeding.
Signsandsymptoms
SignsandsymptomsofacuteupperGIbleeding[1]includethefollowing:
Hematemesis
Melena
Hematochezia
Syncope
Presyncope
Dyspepsia
Epigastricpain
Heartburn
Diffuseabdominalpain
Dysphagia
Weightloss
Jaundice
SeeClinicalPresentationformoredetail.
Diagnosis
Workupincludesthefollowing:
Orthostaticbloodpressure
Completebloodcountwithdifferential
Hemoglobinlevel
Typeandcrossmatchblood
Basicmetabolicprofile,bloodureanitrogen,andcoagulationprofile
Calciumlevel
Gastrinlevel
Endoscopy
Chestradiography
Nasogastriclavage
Angiography(ifbleedingpersistsandendoscopyfailstoidentifyableeding
site)
Computedtomographyscanningandultrasonographymaybeindicatedforthe
evaluationofthefollowing[2]:
Liverdiseasewithcirrhosis
Cholecystitiswithhemorrhage
Pancreatitiswithpseudocystandhemorrhage
Aortoentericfistula
SeeWorkupformoredetail.
http://emedicine.medscape.com/article/187857overview
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Management
Treatmentincludesthefollowing:
Securetheairway
Insertbilateral,16gauge(minimum),upperextremity,peripheralintravenous
lines
Replaceeachmilliliterofbloodlosswith3mLofcrystalloidfluid
Inpatientswithseverecoexistingmedicalillnesses,pulmonaryartery
catheterinsertionformonitoringhemodynamiccardiacperformance
Foleycatheterplacementforcontinuousevaluationofurinaryoutputasa
guidetorenalperfusion
Endoscopichemostatictherapyforbleedingulcersandvarices
Surgicalrepairofperforatedviscus
Forhighriskpepticulcerpatients,highdoseintravenousprotonpump
inhibitors
Indicationsforsurgeryinpatientswithbleedingpepticulcersincludethefollowing:
Severe,lifethreateninghemorrhagenotresponsivetoresuscitativeefforts
Failureofmedicaltherapyandendoscopichemostasiswithpersistent
recurrentbleeding
Acoexistingreasonforsurgery(eg,perforation,obstruction,malignancy)
Prolongedbleeding,withlossof50%ormoreofthepatient'sbloodvolume
Asecondhospitalizationforpepticulcerhemorrhage
SeeTreatmentandMedicationformoredetail.
Background
Acutegastrointestinal(GI)bleedingisapotentiallylifethreateningabdominal
emergencythatremainsacommoncauseofhospitalization.Uppergastrointestinal
bleeding(UGIB)isdefinedasbleedingderivedfromasourceproximaltothe
ligamentofTreitz.
TheincidenceofUGIBisapproximately100casesper100,000populationperyear.
[3]BleedingfromtheupperGItractisapproximately4timesascommonas
bleedingfromthelowerGItractandisamajorcauseofmorbidityandmortality.
MortalityratesfromUGIBare610%overall. [3](SeeEpidemiology,below.)
Thediagnosisofandtherapyfornonvaricealuppergastrointestinalbleeding(UGIB)
hasevolvedsincethelate20thcenturyfrompassivediagnostic
esophagogastroduodenoscopywithmedicaltherapyuntilsurgicalinterventionwas
neededtoactiveinterventionwithendoscopictechniquesfollowedbyangiographic
andsurgicalapproachesifendoscopictherapyfails. [4](SeeWorkupandTreatment
andManagement,below.)
Varicealhemorrhageisnotdiscussedinthisarticlebecausetheunderlying
mechanismsofbleedingaredifferentandrequiredifferenttherapies.
Theunderlyingmechanismsofnonvaricealbleedinginvolveeitherarterial
hemorrhage,suchasinulcerdiseaseandmucosaldeeptears,orlowpressure
venoushemorrhage,asintelangiectasiasandangioectasias.Invariceal
hemorrhage,theunderlyingpathophysiologyisduetoelevatedportalpressure
transmittedtoesophagealandgastricvaricesandresultinginportalgastropathy.A
bleedingulcerisseenbelow.(SeeEtiology,below.)
GotoPediatricGastrointestinalBleedingforcompleteinformationonthistopic.
Ulcerwithactivebleeding.
InpatientswithUGIB,comorbidillness,ratherthanactualbleeding,isthemajor
causeofdeath.Comorbidillnesshasbeennotedin50.9%ofpatients,withsimilar
occurrencesinmales(48.7%)andfemales(55.4%).
Oneormorecomorbidillnesseshavebeennotedin98.3%ofmortalitiesinUGIB
in72.3%ofpatients,comorbidillnesseshavebeennotedastheprimarycauseof
death. [5,6](SeeEpidemiologyandPrognosis,below.)
Significantcomorbiditieshavebecomemoreprevalentasthepatientpopulation
withUGIBhasbecomeprogressivelyolder.Inaretrospectivechartreviewby
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Yavorskietal,73.2%ofdeathsoccurredinpatientsolderthan60years. [6](See
EpidemiologyandPrognosis,below.)
Rebleedingorcontinuedbleedingisassociatedwithincreasedmortalitytherefore,
differentiatingthepatientwithalowprobabilityofrebleedingandlittlecomorbidity
fromthepatientathighriskforrebleedingwithseriouscomorbiditiesisimperative.
(SeeClinicalPresentationandWorkup,below.)
PepticulcerdiseaseandUGIB
Pepticulcerdisease(PUD)remainsthemostcommoncauseofUGIB.Ina
literaturereviewinvolvingmorethan10,000patientswithUGIB,PUDwas
responsiblefor2740%ofallbleedingepisodes. [7]Highriskpatientpopulationsat
riskforPUDincludethosewithahistoryofalcoholabuse,chronicrenalfailure,
and/ornonsteroidalantiinflammatorydrug(NSAID)use. [8]
PepticulcerdiseaseisstronglyassociatedwithHelicobacterpyloriinfection.The
organismcausesdisruptionofthemucousbarrierandhasadirectinflammatory
effectongastricandduodenalmucosa,reducingmucosaldefensesandincreasing
backdiffusionofacidbylooseningtightcellularjunctions.(RatesofHpylori
infectionarereportedlylowerinpatientswithcomplicatedulcerdiseasethanin
patientswithuncomplicatedulcers.Hoskingetalreporteda71%incidenceofH
pyloriinfectioninpatientswithbleedingduodenalulcerspatientswithnonbleeding
ulcershadanincidenceof93%.)Thisdiscrepancymaybeduetothedecreasein
sensitivityofbiopsyinpatientswithulcerbleeding. [9]
EradicationofHpyloribeendemonstratedtoreducetheriskofrecurrentulcersand,
thus,recurrentulcerhemorrhageaftertheinitialepisode.Infact,theproportionof
UGIBcasescausedbypepticulcerdiseasehasdeclined, [10]aphenomenonthatis
believedtobeduetotheuseofprotonpumpinhibitors(PPIs)andHpyloritherapy.
Duodenalulcersaremorecommonthangastriculcers,buttheincidenceofbleeding
isidenticalforboth.Inmostcases,thebleedingiscausedbytheerosionofan
arteryinthebaseoftheulcer.Inapproximately80%ofpatients,bleedingfroma
pepticulcerstopsspontaneously. [7]
Initialendoscopicattemptstomaintainhemostasishaveahighfailurerate.
Bleedingvesselslargerthan1.5mmindiameterareassociatedwithanincreased
mortalityrateduetothedifficultyofproducingadequatehemostasiswiththermal
probes.
Aminorityofpatientsexperiencerecurrentbleedingafterendoscopictherapy,and
thesecasesareusuallyassociatedwithriskfactorsforrebleeding.Thesefactors
includeageolderthan60years,thepresenceofshockuponadmission,
coagulopathy,activepulsatilebleeding,andthepresenceofcardiovasculardisease.
(Theappearanceoftheulceratthetimeofendoscopyprovidesimportant
informationregardingtheriskofrebleeding.)Thesecircumstancesareassociated
withapoorerprognosisandahighermortalityrate. [11]
Despitethedangersassociatedwithableedingpepticulcer,astudybySungetal
of10,428casesofsuchbleeding(in9,375patients)foundthatmostpatientdeaths
werenotcausedbyit. [12]Ofthe577deathsthatoccurredinthecohort,almost80%
resultedfromothercauses,includingmultiorganfailure,pulmonaryconditions,and
terminalmalignancy.Theauthorsconcludedthatthemanagementofpatientswith
pepticulcersshouldfocusnotonlyonhemostasisbutalsoonloweringtheriskof
multiorganfailureandcardiopulmonarydeath.
Recurrentbleedingriskinpepticulcers
Forrestetalwerethefirsttoclassifythestigmataofhemorrhagefrompepticulcers.
Basedontheseclassifications,theriskofrecurrentbleedingcanbepredicted.The
ulcersathighestriskforrebleedingarethosethatinvolveactivearterialbleedingor
thosewithavisible,protuberant,nonbleedingvesselinthebaseoftheulcer.The
studynotonlycorrelatedtheincidenceofrebleedingwiththestigmataofrecent
bleedingandtheendoscopicappearanceofanulcer,butalsodetermined
prognosticinformationregardingtheneedforsurgery.Mortalitywasalsocorrelated.
[13]
InpatientswithHpyloriinfection,therateofrecurrentbleedingisextremelylow.
ThisiswhydocumentingthepresenceofHpyloriandaggressivelytreatingthe
infectionareimportant.
PatientswhoarenotinfectedwithHpylorimayrequireasubsequentacidlowering
surgicalprocedureorlongtermmedicaltherapyforrecurrentulcerdiseaseand
bleeding.
OthercausesofUGIB
OthermajorcausesofUGIBaremucosaltearsoftheesophagusorfundus
(MalloryWeisstear),erosivegastritis,erosiveesophagitis,Dieulafoylesion,gastric
cancer,andulceratedgastricleiomyoma.
Patientswithchronicliverdiseaseandportalhypertensionareatincreasedriskfor
varicealhemorrhageandportalgastropathyinadditiontoulcerhemorrhage.
RarecausesofUGIBincludeaortoentericfistula,gastricantralvascularectasia,
angiectasias,andOslerWeberRendusyndrome.
Anaortoentericfistularesultsfromtheerosionoftheaorticgraftintothebowel
lumen,usuallythethirdorfourthportionoftheduodenum.Theresultisadirect
communicationbetweentheaorticgraftlumenandthebowellumen.Most
aortoentericfistulasinvolvetheproximalaorticanastomoticsutureline.
UGIBcanalsoresultfromacutestressgastritis,adiseaseprocesscharacterizedby
diffusesuperficialmucosalerosionsthatappearasdiscreteareasoferythema. [13]
Thebleedingisusuallymildandselflimitingandrarelyprogressestolife
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threateninghemorrhage.
Inintensivecareunit(ICU)patients,theincidenceofclinicallysignificantGI
bleeding(eg,hypotension,transfusion)fromacutestressgastritiswasfoundtobe
1.5%. [14]Stressgastritisandmucosalulcerationarehistoricallyassociatedwith(1)
headinjurieswithassociatedelevationsinintracranialpressureand(2)burninjuries.
ThesestressulcersarecalledCushingulcersandCurlingulcers,respectively.
AngiodysplasiaoftheupperGItractaccountsfor24%ofbleedinglesions. [7]The
conditionisalsoacauseoflowerGIbleedingin6%ofcases. [13]Thelesionisa
vascularmalformationthatrepresentsanabnormaldilationofmucosaland
submucosalvessels.
Histologically,angiodysplasiasaredilated,thinwalledvascularchannelsthatappear
macroscopicallyasaclusterofcherryspots.WhenlocatedintheupperGItract,
theymostcommonlyinvolvethestomachandduodenum.Thelesionscanbe
acquiredorcongenital,asinhereditaryhemorrhagictelangiectasiaandRendu
OslerWebersyndrome.
Theacquiredangiodysplasiasarecommonlyfoundinpatientswithchronicrenal
failurerequiringhemodialysisandwithaorticvalvulardisease(especiallyaortic
stenosis).Otherdiseases,suchascirrhosisandvonWillebranddisease,are
associatedwithahigherfrequencyofangiodysplasias.Mostlesionsaresmaller
than1cmindiameterandcanbemultiplein66%ofpatients. [7]
Etiology
UlcerrelatedUGIB
Aspreviouslymentioned,pepticulcerdiseaseisstronglyassociatedwithHpylori
infection.Theorganismcausesdisruptionofthemucousbarrierandhasadirect
inflammatoryeffectongastricandduodenalmucosa.
IncasesofulcerassociatedUGIB,astheulcerburrowsdeeperintothe
gastroduodenalmucosa,theprocesscausesweakeningandnecrosisofthearterial
wall,leadingtothedevelopmentofapseudoaneurysm.Theweakenedwall
ruptures,producinghemorrhage.
Theflowthroughthevesselvarieswiththefourthpoweroftheradiusthus,small
increasesinvesselsizecanmeanmuchlargeramountsofbloodflowandbleeding,
withmoreseverehypotensionandmorecomplications,especiallyinolderpatients.
Visiblevesselsusuallyrangefrom0.31.8mm.
Exsanguinatinghemorrhagehasbeenreportedfromlargervessels.Thelarger
vesselsarelocateddeeperinthegastricandduodenalsubmucosaandserosa.
Largerbranchesoftheleftgastricarteryarefoundhighonthelessercurvature,
whilethepancreatoduodenalarteryanditsmajorbranchesarelocated
posteroinferiorlyintheduodenalbulb.
VomitingrelatedUGIB
Duringvomiting,theloweresophagusandupperstomachareforciblyinverted.
Vomitingattributabletoanycausecanleadtoamucosaltearofthelower
esophagusorupperstomach.Thedepthoftheteardeterminestheseverityofthe
bleeding.Rarely,vomitingcanresultinesophagealrupture(Boerhaavesyndrome),
leadingtobleeding,mediastinalairentry,leftpleuraleffusion(salivaryamylasecan
bepresent)orleftpulmonaryinfiltrate,andsubcutaneousemphysema.
MalloryWeisstearsinUGIB
MalloryWeisstearsaccountfor15%ofacuteupperGIhemorrhage. [7]Kenneth
MalloryandSomaWeissfirstdescribedthesyndromein1929. [15]Themassive
UGIBresultsfromatearinthemucosaofthegastriccardia.
Thislinearmucosallacerationistheresultofforcefulvomiting,retching,coughing,
orstraining.Theseactionscreatearapidincreaseinthegradientbetween
intragastricandintrathoracicpressures,leadingtoagastricmucosaltearfromthe
forcefuldistentionofthegastroesophagealjunction. [16]In8090%ofcases,thisisa
single,1.75to2.5cmmucosaltearalongthelessercurveofthestomachjust
distaltothegastroesophagealjunction. [15]
GotoMalloryWeissTearforcompleteinformationonthistopic.
AcutestressgastritisinUGIB
Acutestressgastritisresultsfrompredisposingclinicalconditionsthathavethe
potentialtoalterlocalmucosalprotectivebarriers,suchasmucus,bicarbonate,
bloodflow,andprostaglandinsynthesis.Anydiseaseprocessthatdisruptsthe
balanceofthesefactorsresultsindiffusegastricmucosalerosions.
Thisismostcommonlyobservedinpatientswhohaveundergoneepisodesof
shock,multipletrauma,acuterespiratorydistresssyndrome,systemicrespiratory
distresssyndrome,acuterenalfailure,andsepsis.
Theprincipalmechanismsinvolvedaredecreasedsplanchnicmucosalbloodflow
andalteredgastricluminalacidity.
DieulafoylesionsinUGIB
TheDieulafoylesion,firstdescribedin1896,isavascularmalformationofthe
proximalstomach,usuallywithin6cmofthegastroesophagealjunctionalongthe
lessercurvatureofthestomach.However,itcanoccuranywherealongtheGItract.
Thislesionaccountsfor25%ofacuteUGIBepisodes. [17]
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Endoscopically,thelesionappearsasalargesubmucosalvesselthathasbecome
ulcerated.Becauseofthelargesizeofthevessel,bleedingcanbemassiveand
brisk.Thevesselruptureusuallyoccursinthesettingofchronicgastritis,whichmay
inducenecrosisofthevesselwall.Alcoholconsumptionisreportedlyassociated
withtheDieulafoylesion.
Inareviewof149cases,theDieulafoylesionmostlyoccurredinmenandmostlyin
thoseintheirthirdtotenthdecade. [18]
NSAIDsinUGIB
NSAIDscausegastricandduodenalulcersbyinhibitingcyclooxygenase,which
causesdecreasedmucosalprostaglandinsynthesisandresultsinimpairedmucosal
defenses.DailyNSAIDusecausesanestimated40foldincreaseingastriculcer
creationandan8foldincreaseinduodenalulcercreation. [13]
LongtermNSAIDuseisassociatedwitha20%incidenceinthedevelopmentof
mucosalulceration. [19]Medicaltherapyincludesavoidingtheulcerogenicdrugand
beginningahistamine2(H2)receptorantagonistoraprotonpumpinhibitorthat
providesmucosalprotection.
Epidemiology
Annually,approximately100,000patientsareadmittedtoUShospitalsfortherapy
forUGIB.
UGIBisacommonoccurrencethroughouttheworld.InFrance,areportconcludes
thatthemortalityfromUGIBhasdecreasedfromabout11%to7%however,a
similarreportfromGreecefindsnodecreaseinmortality.Inanationwidestudy
fromSpain,UGIBwas6timesmorecommonthanlowerGIbleeding. [20]
TheincidenceofUGIBis2foldgreaterinmalesthaninfemales,inallagegroups
however,thedeathrateissimilarinbothsexes. [6]
ThepopulationwithUGIBhasbecomeprogressivelyolder,withaconcurrent
increaseinsignificantcomorbiditiesthatincreasemortality.Mortalityincreaseswith
olderage(>60y)inmalesandfemales. [19]
Prognosis
Aspreviouslymentioned,ageolderthan60yearsisanindependentmarkerfora
pooroutcomeinuppergastrointestinalbleeding(UGIB), [21]withthemortalityrate
rangingfrom1225%inthisgroupofpatients.
TheAmericanSocietyforGastrointestinalEndoscopy(ASGE)groupedpatients
withUGIBaccordingtoageandcorrelatedagecategorytoriskofmortality.The
ASGEfoundamortalityrateof3.3%forpatientsaged2131years,arateof10.1%
forthoseaged4150years,andarateof14.4%forthoseaged7180years. [21]
Thefollowingriskfactorsareassociatedwithincreasedmortality,recurrent
bleeding,theneedforendoscopichemostasis,orsurgery[11,22]:
Ageolderthan60years
Severecomorbidity
Activebleeding(eg,witnessedhematemesis,redbloodpernasogastrictube,
freshbloodperrectum)
Hypotension
Redbloodcelltransfusiongreaterthanorequalto6units
Inpatientattimeofbleed
Severecoagulopathy
Patientswhopresentinhemorrhagicshockhaveamortalityrateofupto30%.
PatientEducation
Forpatienteducationinformation,seetheDigestiveDisordersCenterandthe
HeartburnandGERDCenter.AlsoseethepatienteducationarticleGastrointestinal
Bleeding.
ClinicalPresentation
ContributorInformationandDisclosures
Author
MauriceACerulli,MD,FACP,FACG,FASGE,AGAFAssociateProfessorofClinicalMedicine,AlbertEinstein
CollegeofMedicineofYeshivaUniversityAssociateProfessorofClinicalMedicine,HofstraMedicalSchool
MauriceACerulli,MD,FACP,FACG,FASGE,AGAFisamemberofthefollowingmedicalsocieties:American
AssociationfortheStudyofLiverDiseases,AmericanCollegeofGastroenterology,AmericanCollegeof
Physicians,NewYorkSocietyforGastrointestinalEndoscopy,AmericanGastroenterologicalAssociation,
AmericanMedicalAssociation,AmericanSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
Coauthor(s)
ShahzadIqbal,MDAdvancedEndoscopyFellow,DepartmentofGastroenterology,ColumbiaUniversityMedical
Center
ShahzadIqbal,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiver
Diseases,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,AmericanGastroenterological
Association,AmericanSocietyforGastrointestinalEndoscopy
5/9
8/26/2015
ChiefEditor
BSAnand,MDProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,BaylorCollegeof
Medicine
BSAnand,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyofLiver
Diseases,AmericanCollegeofGastroenterology,AmericanGastroenterologicalAssociation,AmericanSociety
forGastrointestinalEndoscopy
Acknowledgements
JamesdeCaestecker,DOInstructor,DepartmentofSurgery,MCPHahnemannUniversity
JamesdeCaestecker,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons
MichaelAGrosso,MDConsultingStaff,DepartmentofCardiothoracicSurgery,StFrancisHospital
MichaelAGrosso,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,Societyof
ThoracicSurgeons,andSocietyofUniversitySurgeons
DouglasMHeuman,MD,FACP,FACG,AGAFChiefofHepatology,HunterHolmesMcGuireDepartmentof
VeteransAffairsMedicalCenterProfessor,DepartmentofInternalMedicine,DivisionofGastroenterology,
VirginiaCommonwealthUniversitySchoolofMedicine
DouglasMHeuman,MD,FACP,FACG,AGAFisamemberofthefollowingmedicalsocieties:American
AssociationfortheStudyofLiverDiseases,AmericanCollegeofPhysicians,andAmericanGastroenterological
Association
Disclosure:NovartisGrant/researchfundsOtherBayerGrant/researchfundsOtherOtsukaGrant/researchfunds
NoneBristolMyersSquibbGrant/researchfundsOtherScynexisNoneNoneSalixGrant/researchfundsOther
MannKindOther
AlexJacocks,MDProgramDirector,Professor,DepartmentofSurgery,UniversityofOklahomaSchoolof
Medicine
JasonStraus,MDStaffPhysician,DepartmentofSurgery,WrightStateUniversitySchoolofMedicine
JasonStraus,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,American
MedicalAssociation,andSocietyofAmericanGastrointestinalandEndoscopicSurgeons
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
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