A number of medications increase the risk of bleeding including NSAIDs and SSRIs.

SSRIs double the rate of upper gastrointestinal bleeding.[1]

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

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

The causes for upper GI hemorrhage include the following:

• Esophageal causes:
o Esophageal varices
o Esophagitis
o Esophageal cancer
o Esophageal ulcers
o Mallory-Weiss tear

• Gastric causes:
o Gastric ulcer
o Gastric cancer
o Gastritis
o Gastric varices
o Gastric antral vascular ectasia
o Dieulafoy's lesions
• Duodenal causes:
o Duodenal ulcer
o Vascular malformation, including aorto-enteric fistulae. Fistulae are usually secondary to prior vascular surgery and usually occur at the proximal anastomosis at the
third or fourth portion of the duodenum where it is retroperitoneal and near the aorta.[2][3][4]
o Hematobilia, or bleeding from the biliary tree
o Hemosuccus pancreaticus, or bleeding from the pancreatic duct
o Severe superior mesenteric artery syndrome

[edit] Diagnosis
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 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.

[edit] 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)[5]. 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 results[6].

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 Treitz[2]. 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%[3],
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 accurate [7] . Cuellar found the following results:

Determining whether blood is in the gastric aspirate[8]

Positive predictive value Negative predictive value
Finding Sensitivity Specificity
(prevalence of 39%) (prevalence of 39%)
Gastroccult 95% 82% 77% 96%
Physician assessment 79% 55% 53% 20%

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 accurate [9]. Holman found that by 120 seconds after the developer was applied, the Hemoccult test was positive on all control samples.
In a study published regarding a new scoring system called the Glasgow-Blatchford bleeding score in Lancet on January 3, 2009, 16% of patients presenting with upper GI bleed
had GBS score of "0", considered low. Among these patients there were no deaths or interventions needed and the patients were able to be effectively treated in an outpatient
setting. [10][11] [12]

Score is equal to "0" if the following are all present:

1. Hemoglobin level >12.9 g/dL (men) or >11.9 g/dL (women)

2. Systolic blood pressure >109 mm Hg
3. Pulse <100/minute
4. Blood urea nitrogen level <18.2 mg/dL
5. No melena or syncope
6. No past or present liver disease or heart failure

[edit] 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.

[edit] Treatment

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. Vital 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 type
of lesion identified, 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

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 vasopressin 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.

[edit] 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.

[edit] Epidemiology
About 75% of patients presenting to the emergency room with GI bleeding have an upper source [6]. 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 source [5] [8] [13]