What is the definition of upper GI (Gastrointestinal) bleed?

Definition of Upper Gastrointestinal Bleeding

Upper gastrointestinal (GI) bleeding is defined as hemorrhage occurring proximal to the ligament of Treitz, originating from the esophagus, stomach, or duodenum. 1

Clinical Presentation

Upper GI bleeding typically presents with the following manifestations:

• Hematemesis - Vomiting of fresh red blood 1
• Coffee ground vomiting - Vomiting of altered black blood 1
• Melena - Passage of black tarry stools 1
• Hematochezia (less common) - Passage of red blood per rectum, which can occur with massive upper GI bleeding 1, 2

It's important to note that patients presenting with hematemesis and melena generally have more severe bleeding than those presenting with melena alone 1.

Classification of GI Bleeding

Upper GI bleeding can be classified as:

1. Overt bleeding - Patients present with visible signs of bleeding such as hematemesis, melena, or hematochezia 1
2. Occult bleeding - Patients present with iron deficiency anemia or guaiac-positive stools without visible blood loss 1
3. Obscure bleeding - Bleeding with unknown source despite complete GI tract imaging and endoscopic evaluation 1

Common Causes

The most common causes of upper GI bleeding include:

• Peptic ulcer disease (35-50%) - Both gastric and duodenal ulcers 1
• Gastroduodenal erosions (8-15%) 1
• Esophagitis (5-15%) 1
• Mallory-Weiss tears (15%) - Mucosal tears at the gastroesophageal junction 1
• Varices (5-10%) 1
• Vascular malformations (1%) 1
• Upper GI malignancy 1
• Dieulafoy lesion - A tortuous submucosal artery that penetrates through the mucosa 1

Epidemiology and Outcomes

• Nonvariceal causes of UGIB have an incidence of approximately 61-78 cases per 100,000 persons in the United States 1
• Mortality rates range from 2-10% 1
• The incidence of nonvariceal UGIB is almost 5 times higher than that of variceal UGIB 1
• Although 80-85% of cases cease bleeding spontaneously, there is a high risk of rebleeding, massive hemorrhage, and death 1

Prognostic Factors

Patients with UGIB who present with hematochezia (rather than melena) tend to have:

• Higher transfusion requirements
• Greater need for surgery
• Higher mortality rates (13.6% vs 7.5%)

This suggests more severe bleeding and worse outcomes in this subgroup 2.

Management Approach

The initial management of nonvariceal UGIB focuses on:

1. Resuscitation and maintenance of hemodynamic stability
2. Triage (inpatient versus intensive care unit care)
3. Identification of the source of bleeding
4. Bleeding control 1

Esophagogastroduodenoscopy is the first-line diagnostic and therapeutic investigation for most patients with UGIB 1.

Clinical Implications

Understanding the definition and characteristics of upper GI bleeding is crucial for proper risk stratification and management. Early recognition of the source and severity of bleeding can significantly impact patient outcomes and reduce mortality.

When evaluating a patient with suspected UGIB, remember that while hematemesis and melena are the classic presentations, hematochezia with hemodynamic compromise should also raise suspicion for an upper GI source of bleeding 2, 3.

Upper GI bleeding remains a significant cause of morbidity and mortality, requiring prompt evaluation and management to improve patient outcomes.