What are the common symptoms of an upper gastrointestinal bleed?

1.

Kovacs, Thomas O., Jensen, Dennis M. (2024). In Goldman-Cecil Medicine (pp. 882). DOI: 10.1016/B978-0-323-93038-3.00121-0

Upper GI bleeding occurs proximal to the ligament of Treitz. Patients with upper GI bleeding usually present with hematemesis (vomiting blood or coffee-ground material) or melena (black, tarry stool). In large series, about 50% of patients have hematemesis and melena, about 30% have hematemesis alone, and about 20% have only melena. On occasion, however, hematochezia (passage per rectum of red blood or clots) may be the only manifestation of a bleeding ulcer, and about 15% of all patients who present with hematochezia have an upper GI source. Peptic ulcer disease (Fig. 121-1) is the most common cause of acute upper GI hemorrhage, accounting for about 40% of cases. Other common causes are esophageal and gastric varices and erosive esophagitis. Variceal bleeding, which occurs in the setting of portal hypertension, is discussed inChapter 139. Other conditions, such as Mallory-Weiss tears (Fig. 121-2;Chapter 124), angiodysplasia, watermelon stomach, tumors, and Dieulafoy lesion, occur less frequently than peptic ulcer (Table 121-1). The mortality from nonulcer bleeding is comparable to that from ulcer hemorrhage in high-risk patients, so all causes of upper GI hemorrhage contribute to the morbidity and cost of care associated with it.

2.

McQuaid, Kenneth R. (2024). In Goldman-Cecil Medicine (pp. 850). DOI: 10.1016/B978-0-323-93038-3.00118-0

GI bleeding (Chapter 121) may be acute and clinically apparent (overt) or chronic, slow, and clinically inapparent (occult). The location of acute GI bleeding is described as either upper or lower, according to whether the source is proximal or distal to the ligament of Treitz (distal duodenum). Upper GI bleeding, which is three times more common than lower GI bleeding, is manifested by bloody emesis (hematemesis), coffee ground emesis, and, in most cases, black stools (melena). Common causes of significant bleeding are peptic ulcer disease, esophageal varices, Mallory-Weiss tears, erosive gastritis or esophagitis, and vascular ectasias.Major lower GI bleeding is manifested by large-volume maroon or bright red bloody stools (hematochezia). Although 80 to 90% of patients with hematochezia have a lower source of bleeding, massive upper GI bleeding also may cause hematochezia. Approximately 95% of major lower GI bleeding arises from the colon and 5% from the small intestine. Lower GI bleeding is increased in patients older than50 years, in whom diverticulosis accounts for 60% of cases; the remainder are due to ischemia, neoplasms, ulcers, vascular ectasias, or hemorrhoids. In patients younger than 50 years, bleeding is more commonly attributable to inflammatory bowel disease, hemorrhoids, or infectious colitis, but the incidence of colonic neoplasia is increasing in patients ages 40 to 50 years. Occult GI bleeding refers to GI blood loss that is small in volume and not apparent to the patient but is detectable by tests for fecal occult blood. Chronic occult bleeding may result in iron deficiency anemia.Both upper endoscopy and colonoscopy should be performed to look for a source of occult bleeding, most commonly gastroesophageal or colonic neoplasia, erosive esophagitis or gastritis, ulcer disease, or vascular ectasia.

3.

Elsevier ClinicalKey Clinical Overview

Basic Information Acute UGIB (upper gastrointestinal bleeding) by convention refers to bleeding in the gastrointestinal tract from anywhere proximal to the ligament of Treitz Typical presenting symptoms include melena, hematemesis, and coffee-ground emesis Incidence is 67 per 100,000 people annually in the United States Acute UGIB leads to 300,000 hospitalizations annually, with mortality estimated between 3.5% to 10% Important risk factors exist that can increase the likelihood of acute UGIB While the mainstay of diagnosis and treatment is upper endoscopy, important pre- and postendoscopic interventions and therapies can improve patient outcomes

Summary Acute UGIB (upper gastrointestinal bleeding) is a common diagnosis, particularly in patients with chronic liver disease, recent NSAID use, or anticoagulant/antiplatelet agent use Severity can range from mild (eg, can be managed outpatient) to life-threatening, and scoring systems exist to assist with triaging low-risk patients who could pursue outpatient management (Glasgow Blatchford score) Most pertinent aspects of symptom history are reported hematemesis and/or melena Melena on rectal examination is the most specific physical examination finding suggestive of acute UGIB Relevant laboratory tests for diagnosis other than CBC include basic chemistries, with elevated BUN to creatinine ratio greater than 30 suggestive of acute UGIB Initial assessment and management should focus on triage, resuscitation, and restrictive transfusion strategy Medical management in advance of endoscopy primarily consists of IV proton pump inhibitors, with additional measures such as vasoactive medications and antibiotics indicated in special circumstances of portal hypertensive bleeding

Workup Chronic liver disease and/or excessive alcohol consumption raises likelihood of portal hypertensive bleeding such as variceal hemorrhage Chronic kidney disease and severe valvular pathology can increase risk for bleeding angiodysplasia Helicobacter pylori infection and NSAID use raise the risk of peptic ulcer disease Coronary and other vascular stents with concomitant antithrombotic use raise risk of acute UGIB Aortic pathology/instrumentation may lead to aortoenteric fistula Prior intra-abdominal surgery (eg, Roux-en-Y gastric bypass) can lead to anastomotic ulcers Hematemesis/coffee-ground emesis should be inquired about as both suggest acute UGIB Melena is the most important symptom to elicit; patient-reported history of melena has LR (likelihood ratio) range of 5.1 to 5.9 for acute UGIB Hematochezia may also occur in the setting of very significant UGIB. Typically patients are hemodynamically unstable Palpitations, dyspnea, and fatigue can be indicative of blood loss Medications Anticoagulant and antiplatelet use raise risk of acute UGIB NSAID use can cause peptic ulcer disease Charcoal, bismuth, and oral iron all may cause darkening of stool that can masquerade as melena

4.

Elsevier ClinicalKey Clinical Overview

Diagnosis Epigastric tenderness is the most common finding in patients with gastric or duodenal ulcers With gastrointestinal bleeding Hematemesis (frank blood or coffee-ground emesis) and/or melena; hematochezia less commonly, with a briskly bleeding ulcer Bleeding may be occult, with heme-positive stool detected on routine rectal examination Tachycardia and hypotension may be present in association with hemodynamically significant bleeding With perforated ulcer Generalized abdominal tenderness, guarding, and rigidity Tachycardia and hypotension may be present With gastric outlet obstruction Increased abdominal girth Decreased bowel sounds Succussion splash

5.

Wilkins T, Wheeler B, Carpenter M. American Family Physician. 2020;101(5):294-300.

Publish date: March 0, 2020.

Upper gastrointestinal (GI) bleeding is defined as hemorrhage from the mouth to the ligament of Treitz. Common risk factors for upper GI bleeding include prior upper GI bleeding, anticoagulant use, high-dose nonsteroidal anti-inflammatory drug use, and older age. Causes of upper GI bleeding include peptic ulcer bleeding, gastritis, esophagitis, variceal bleeding, Mallory-Weiss syndrome, and cancer. Signs and symptoms of upper GI bleeding may include abdominal pain, lightheadedness, dizziness, syncope, hematemesis, and melena. Physical examination includes assessment of hemodynamic stability, presence of abdominal pain or rebound tenderness, and examination of stool color. Laboratory tests should include a complete blood count, basic metabolic panel, coagulation panel, liver tests, and type and crossmatch. A bolus of normal saline or lactated Ringer solution should be rapidly infused to correct hypovolemia and to maintain blood pressure, and blood should be transfused when hemoglobin is less than 7 g per dL. Clinical prediction guides (e.g., Glasgow-Blatchford bleeding score) are necessary for upper GI bleeding risk stratification and to determine therapy. Patients with hemodynamic instability and signs of upper GI bleeding should be offered urgent endoscopy, performed within 24 hours of presentation. A common strategy in patients with failed endoscopic hemostasis is to attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained. Proton pump inhibitors should be initiated upon presentation with upper GI bleeding. Guidelines recommend high-dose proton pump inhibitor treatment for the first 72 hours post-endoscopy because this is when rebleeding risk is highest. Deciding when to restart antithrombotic therapy after upper GI bleeding is difficult because of lack of sufficient data.