What are the clinical features, diagnosis, and management of upper Gastrointestinal (GI) bleeding?

Clinical Features, Diagnosis, and Management of Upper GI Bleeding

Upper gastrointestinal bleeding requires prompt recognition, resuscitation, and early endoscopic intervention to reduce mortality, with management decisions guided by risk stratification and the underlying cause of bleeding.

Clinical Features

Upper GI bleeding presents with distinctive clinical manifestations:

• Hematemesis: Vomiting of fresh red blood 1
• Coffee ground vomiting: Vomiting of altered black blood 1
• Melena: Passage of black tarry stools 1
• Hemochezia: Red blood per rectum (rare in UGIB, but can occur with massive bleeding) 1
• Hemodynamic instability: Tachycardia, hypotension, and shock in severe cases 2

Patients with hematemesis and melena typically have more severe bleeding than those with melena alone 1.

Common Causes

The most frequent causes of upper GI bleeding include:

Diagnosis	Approximate %
Peptic ulcer	35-50%
Gastroduodenal erosions	8-15%
Esophagitis	5-15%
Varices	5-10%
Mallory-Weiss tear	15%
Vascular malformations	1%
Upper GI malignancy	<5%

A definitive cause is identified in approximately 80% of cases 1.

Diagnosis

Initial Assessment

1. Hemodynamic evaluation: Assess pulse, blood pressure, and signs of shock 2
2. Laboratory tests:
   • Complete blood count
   • Coagulation profile
   • Liver and renal function tests
   • Blood grouping and cross-matching 3

Risk Stratification

Risk assessment should be performed to determine the level of care and timing of interventions:

• High-risk features: Hemodynamic instability, ongoing bleeding, comorbidities 4
• Low-risk features: Stable vital signs, no comorbidities, young age 4

Endoscopy

Endoscopy is the gold standard for diagnosis, allowing for:

• Direct visualization of the bleeding source
• Classification of lesions (e.g., Forrest classification for ulcers)
• Therapeutic intervention 1, 4

Timing: Endoscopy should be performed within 24 hours of presentation, with earlier endoscopy (after resuscitation) for high-risk patients 4.

Management

Immediate Resuscitation

1. Airway protection: Especially important in patients with massive hematemesis
2. Fluid resuscitation: Intravenous fluids to restore hemodynamic stability 2
3. Blood transfusion: Recommended at hemoglobin threshold of 70-80 g/L 4
4. Correction of coagulopathy: Early correction of any clotting abnormalities 2

Pharmacological Therapy

1. Proton pump inhibitors (PPIs):

   • Administer after resuscitation is initiated
   • High-dose therapy after endoscopic treatment for ulcer bleeding 4

2. For suspected variceal bleeding:

   • Vasoactive drugs (e.g., octreotide, terlipressin)
   • Prophylactic antibiotics in patients with cirrhosis 4

3. Prokinetic agents:

   • Erythromycin before endoscopy may improve visualization 4

Endoscopic Therapy

Based on the cause of bleeding:

1. Non-variceal bleeding:

   • Injection therapy
   • Thermal probes
   • Hemoclips for lesions with active bleeding or non-bleeding visible vessels 4

2. Variceal bleeding:

   • Esophageal varices: Band ligation
   • Gastric varices: Tissue adhesive (glue) 4

Management of Rebleeding

Rebleeding is defined as fresh hematemesis/melena with shock, significant drop in CVP, or reduction in hemoglobin >20 g/L over 24 hours 1.

1. Non-variceal rebleeding:

   • Repeat endoscopic therapy
   • Consider interventional radiology or surgery for subsequent bleeding 4

2. Variceal rebleeding:

   • Transjugular intrahepatic portosystemic shunt (TIPS) 4

Post-Endoscopic Care

1. Continued monitoring of vital signs and hemoglobin levels
2. Ongoing medical therapy:
   • High-dose PPIs for ulcer bleeding
   • Continued antibiotics and vasoactive drugs for variceal bleeding 4

Special Considerations

Antithrombotic Therapy

In patients requiring antithrombotic agents, outcomes appear better when these drugs are reintroduced early after bleeding control 4.

Outpatient Management

Patients identified as very low risk can be managed as outpatients, but this requires careful selection 4.

Pitfalls to Avoid

1. Delayed endoscopy in high-risk patients
2. Inadequate resuscitation before endoscopic intervention
3. Failure to recognize and treat comorbidities that may worsen outcomes
4. Inappropriate blood transfusion strategies (over-transfusion can increase rebleeding risk)
5. Delayed recognition of rebleeding

The mortality rate for upper GI bleeding remains significant (2-14%), particularly in elderly patients and those with comorbidities, highlighting the importance of prompt, protocol-driven management 3.