Upper GI Bleeding

Introduction

• Upper gastrointestinal bleeding (UGIB) is a common emergency with bleeding source proximal to the ligament of Treitz.
• It is potentially life-threatening, presenting with haematemesis and/or melaena, and may cause shock.
• Major causes: Peptic ulcer disease, gastritis, oesophageal varices.

Epidemiology

• Incidence: 1 in 1,000 per year, more common in males (1:2 ratio).
• Mortality: 7-10% over the past 50 years.

Aetiology

• Oesophagus: Oesophagitis, varices, malignancy, GORD, Mallory-Weiss tear.
• Stomach: Peptic ulcer disease, Mallory-Weiss tear, gastric varices, gastritis, malignancy.
• Duodenum: Peptic ulcer disease, diverticulum, aortoduodenal fistula, duodenitis.
• Other: Swallowed blood, bleeding disorders, Dieulafoy's lesion, aortoenteric fistula, Hereditary haemorrhagic telangiectasia, Gastric antral vascular ectasia (GAVE).

Peptic Ulcer Disease (PUD)

• Accounts for up to 50% of UGIB, associated with Helicobacter pylori.
• Bleeding usually due to erosions through smaller submucosal blood vessels.

Gastritis

• Inflammation of stomach lining; erosive gastritis accounts for 15-20% of UGIB.
• Requires biopsy to confirm inflammation during endoscopy.
• Classified by location, timing, or pathology type: Antral/pangastritis, acute/chronic, erosive/non-erosive.

Oesophageal Varices

• Abnormal, dilated veins at lower oesophagus end, accounting for 10-20% of UGIB.
• Occur due to portal hypertension, often secondary to chronic liver disease/cirrhosis.

Mallory-Weiss Tear

• Linear mucosal laceration, 5-10% of UGIB.
• Occurs at gastro-oesophageal junction or gastric cardia, following retching/vomiting.

Rare Causes

• Osler-Weber-Rendu Syndrome: Hereditary haemorrhagic telangiectasia.
• GAVE: Gastric antral vascular ectasia, known as "watermelon stomach."

Risk Factors

• Increased risk: NSAIDs, anticoagulants, alcohol abuse, chronic liver/kidney disease, advancing age, previous PUD or H. pylori infection.

Clinical Features

• Symptoms: Haematemesis, dizziness, syncope, weakness, abdominal pain, dyspepsia, heartburn, melaena, haematochezia, weight loss.
• Signs: Dehydration, pallor, confusion, tachycardia and hypotension, abdominal tenderness, stigmata of liver disease, telangiectasia.

Investigations & Diagnosis

• Main investigation: Upper GI endoscopy (diagnostic and therapeutic).
• Bedside tests: Regular observations, ECG, urine output monitoring.
• Blood tests: FBC, blood gas, U&Es, LFTs, clotting, group & save.
• Imaging: Chest X-ray for aspiration and perforation evaluation.

Scoring Systems

• Blatchford Score: During primary assessment, indicates low risk for scores of 0.
• Rockall Score: Includes age, shock, co-morbidity, diagnosis, and endoscopic findings.

Management

• Initial resuscitation: Airway, breathing, circulation focus.
• Endoscopy: Immediate for unstable patients, within 24 hours for others.
• Non-variceal bleeding treatment: Mechanical and thermal techniques with adrenaline.
• Variceal bleeding management: Terlipressin, prophylactic antibiotics, band ligation.

Failed Intervention Options

• Re-bleeds: Sengstaken-Blakemore tube, oesophageal stent, TIPS procedure.

Last updated: March 2021

Author: A dedicated team of UK doctors aiming to simplify medical learning.