Bleeding from the gastrointestinal tract proximal to ligament of Treitz is known as upper gastrointestinal bleed. It is an important medical emergency and outcome is influenced by presence or absence of liver disease. Prognosis depends on the presence of comorbities, severity of bleeding and endoscopic findings.
The ratio of upper to lower GI bleeding is 5:1. It occurs in around 50-100 per 100,000 hospital admissions. 30% of the patients are older than 65 years, 80% are self-limited and 20% of patients who have recurrent bleeding (within 48-72 hrs) have poor prognosis.
Presentations may vary and patient may present with:
Upper GI bleed may be caused by duodenal, gastric or esophageal ulcers, esophageal or gastric varices, Mallory-Weiss tears, gastroduodenal erosions, erosive esophagitis or malignancy.
Approach to the patient
BP < 100 Pulse > 100
Postural Hypotension > 10 mmHg
History: Drugs history (NSAID, anti-thrombotic agents)
Intravenous line maintenance with 2 large bore cannula
Blood for grouping/cross match
Intravenous Omeprazole 80 mg bolus and then 8 mg/hour
Monitor urine output
Blood transfusion – Hematocrit is maintained at 30% in the elderly, 20-25% in younger patients, 25-28% in portal hypertension.
Upper GI Endoscopy
In acute GI bleeding, immediate assessment is followed by stabilization of hemodynamic status, identification of source of bleeding, stoppage of active bleeding, treating the underlying cause and prevention of recurrent bleeding.
Endoscopy is only performed after adequate resuscitation and is useful in diagnosis, prognosis and treatment. Therapeutic endoscopy may be performed with:
- Injection therapy for duodenal ulcers
- Endoscopic variceal band ligation (EVBL) for varices
- Injection therapy for varices
- Argon plasma coagulation (APC) for angiodysplasia
When pharmacological and endoscopic therapies are not successful, transjugular intrahepatic portal shunts (TIPS) or porta-caval shunt surgery may be considered.