Upper Gastrointestinal Bleeding

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Introduction

Upper gastrointestinal bleeding is a bleeding from the lower oesophagus, stomach or duodenum up to the level of ligament of Treitz.

It occurs worldwide and is responsible for significant mortality and morbidity.

Causes of upper gastrointestinal bleeding

Major causes of upper GI bleeding include:

  • Bleeding from Peptic ulcer disease
  • Bleeding from oesophageal and gastric varices
  • Bleeding from mallory-Weiss tear
  • Bleeding from NSAID-related mucosal bleeding
  • Bleeding from neoplasia

Bleeding is either from rupture of engorged varices or from disruption of the oesophageal or gastro-duodenal mucosa with ulceration or erosion into an underlying vessel.

Clinical features of upper gastrointestinal bleeding

Depends on whether the bleeding is acute or chronic, mild or severe
Various presentations:

  1. Haemetemesis
  2. Melaena
  3. Haematochezia
  4. Hypovolaemia
  5. Iron deficiency anaemia (with its
    associated symptoms)

Differential diagnoses

  • Black stools from ingestion of iron tablets
  • Haematemesis/melaena from previously swallowed blood (from the upper respiratory tract and oral cavity)

Complications

Complications of upper gastrointestinal bleeding include the following:

  1. Hypovalaemic shock
  2. Congestive heart failure from chronic severe anaemia

Investigations

  1. Upper gastrointestinal endoscopy:
    • picks up lesions in 90% of cases
  2. Upper gastrointestinal barium radiography:
    • 80% detection rate
  3. Selective mesenteric arteriography
  4. Radio isotope scanning
  5. Stool-occult blood test
  6. Full Blood Count

Treatment for upper gastrointestinal bleeding

Treatment objectives

  1. Restore and maintain haemodynamic status
  2. Control bleeding
  3. Prevent recurrence of bleeding

Non-drug treatment

  1. Carefully monitor vital signs (pulse, blood pressure, respiration and temperature) as frequently as necessitated by the patient’s
    condition
  2. Insert a nasogastric tube to aspirate
    gastric contents and/or to introduce agents to constrict the blood vessels.
  3. Blood transfusion: whole blood (acute bleeding) or packed cells (chronic) bleeding.
    • Up to 5-6 pints of blood may be needed in severe cases
  4. Plasma expanders in the absence of blood
  5. Continuous Central Venous Pressure (CVP) monitoring

Drug treatment

A. Bleeding peptic ulcers/erosions

1. Proton Pump Inhibitors
Omeprazole 20 mg orally once daily for 4 weeks

Or:

Omeprazole 40 mg by slow intravenous injection over 5 minutes once daily until patient can take orally

2. Anti-Helicobacter pylori therapy

3. Endoscopic treatment for actively bleeding ulcer or visible non-bleeding vessel

4. Injection therapy with 98% alcohol (total volume less than 1mL)

Or:

Injection therapy with epinephrine
(1:10,000) up to 1mL

Or:

Thermal coagulation with heat probe

Or:

Laser therapy

B. Bleeding varices

  • Intravenous Octreotide 50 microgram stat, then infusion or 25-50 microgram hourly for 24-48 hours, until endoscopy
  • Intravenous vasopressin 20 units over 20 minutes bolus then infusion of 0.1 – 0.5  units/min

Plus:

Intravenous nitroglycerin 40 microgram/min (titrated upward to maintain systolic blood pressure above 90 mmHg)

Endoscopic treatment

  • Variceal band ligation
  • Injection sclerotherapy: equal volume mixture of 3% sodium tetradecyl sulfate, 98% ethanol, sodium chloride 0.9% injection (2-5ml/site; maximum 50 mL)

Radiologic therapy

  • Venous embolization
  • Transjugular Intrahepatic Portosystemic Shunt (TIPS)
  • Oesophageal transection and devascularization

Liver transplant

  • Peptic ulcers/erosions/tumours

Surgical repair or resection as appropriate

Supportive care

  • Monitor vital signs and urine output to detect early features of hypovolaemic shock
  • Look out for features of hepatic encephalopathy

Notable adverse drug reactions

  • Vasopressin can cause abdominal cramps.
  • It lowers blood pressure drastically:
    • worsen ischaemic heart disease

How to Prevent upper gastrointestinal bleeding

Peptic ulcers/erosions related upper gastrointestinal bleeding

  1. Avoid NSAIDs.
  2. Treat H. pylori infection
  3. Oesophageal varices
  4. β blockers (propranolol 40 mg orally 12 hourly & titrate up to 160 mg depending on the heart rate)
  5. Maintenance sclerotherapy

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