What is the etiology, presentation, management, and potential complications of Upper Gastrointestinal Bleeding (UGIB) in patients with varying demographics and past medical history, including liver disease?

Upper Gastrointestinal Bleeding: Comprehensive Overview

Definition and Epidemiology

Upper gastrointestinal bleeding (UGIB) refers to hemorrhage occurring proximal to the ligament of Treitz, originating from the esophagus, stomach, or duodenum. 1

• Nonvariceal UGIB has an incidence of approximately 61-78 cases per 100,000 persons annually, with mortality ranging from 2-10% 1
• Nonvariceal UGIB is nearly 5 times more common than variceal UGIB 1
• 80-85% of UGIB cases cease spontaneously, but carry high risk of rebleeding, massive hemorrhage, and death 1, 2
• Historical mortality rates ranged from 10-14%, though recent data show declining trends in some regions 1

Etiology

Nonvariceal Causes (Most Common)

Peptic ulcer disease is the leading cause of nonvariceal UGIB, primarily related to Helicobacter pylori infection or NSAID use. 1, 2

Additional nonvariceal etiologies include:

• Gastric erosions and stress-related mucosal disease, particularly prevalent in critically ill patients with mechanical ventilation, coagulopathy, and renal failure 2
• Mallory-Weiss tears from forceful vomiting or retching 1, 2
• Esophagitis and duodenitis as inflammatory causes 2
• Dieulafoy lesion (1-2% of acute bleeding): tortuous submucosal artery penetrating the mucosa, commonly at the posterior gastric wall 2
• Neoplasms including gastric cancer and hepatocellular carcinoma eroding into duodenum 2
• Angiodysplasia and vascular malformations 2

Rare but Critical Causes

• Hemosuccus pancreaticus: responsible for approximately 1 in 500 cases of UGIB 3, 2
• Hemobilia (bleeding into biliary tree) 2
• Aortoenteric fistula: rare but potentially catastrophic 1, 2
• Pancreatitis-related bleeding 1, 2

Iatrogenic and ICU-Specific Causes

• Endoscopic complications: EUS-guided biopsies, ERCP-related injury, delayed hemorrhage from biliary metallic stenting 2
• Surgical complications: extrahepatic arterial injury after pancreatic surgery, stomal marginal ulcers 2
• Esophageal or upper GI stent placement for obstruction 2

Variceal Causes

Esophageal and gastric varices occur more frequently in patients with cirrhosis, representing the primary cause of variceal bleeding. 2, 4

• In cirrhotic populations, variceal bleeding represents 33.3% of UGIB cases 4

Clinical Presentation

Overt Bleeding Manifestations

UGIB most frequently presents with hematemesis or melena, though a minority present with hematochezia. 1

Specific presentations include:

• Melena (87.2% of cases): black, tarry stools indicating upper GI source 4
• Hematemesis (69.7% of cases): vomiting of blood or coffee-ground material 4
• Postural dizziness (73.8% of cases): indicating hemodynamic compromise 4
• Hematochezia: bright red blood per rectum, less common but possible with brisk upper GI bleeding 1

Occult and Obscure Bleeding

• Occult GIB: guaiac-positive stools or iron deficiency anemia without visible blood loss 1
• Obscure GIB: bleeding with unknown source despite complete GI tract imaging and endoscopic evaluation 1

Critical Clinical Caveat

Nasogastric aspirate may be negative in 3-16% of patients with confirmed upper GI bleeding, so negative aspirate does not exclude UGIB. 2

Initial Management and Resuscitation

Immediate Priorities

Aggressive volume resuscitation and hemodynamic stabilization must precede diagnostic efforts. 2, 5

The initial management algorithm includes:

1. Risk stratification using validated prognostic scales (e.g., Glasgow-Blatchford Score, Rockall Score) 1
2. Restrictive red blood cell transfusion policy unless the patient has cardiovascular disease 6
3. Triage decision: inpatient versus intensive care unit care based on hemodynamic stability 1

Pre-Endoscopic Pharmacologic Therapy

Intravenous proton pump inhibitor (PPI) therapy should be initiated before endoscopy as it may downstage the lesion. 1, 6

Additional pre-endoscopic interventions:

• Erythromycin administration to improve endoscopic visualization 6
• Prophylactic antibiotics for patients with cirrhosis 6
• Vasoactive medications (e.g., octreotide, terlipressin) for suspected variceal bleeding in cirrhotic patients 6

What NOT to Use

Tranexamic acid should not be used in UGIB management. 6

Diagnostic Approach

First-Line Investigation

Esophagogastroduodenoscopy (EGD) is the first-line diagnostic and therapeutic investigation, recommended within 24 hours of presentation once hemodynamic stability is achieved. 1, 7, 2, 5

Timing considerations:

• Early endoscopy (within 24 hours) is emphasized in international guidelines 1
• Endoscopy should be performed as soon as hemodynamic stabilization is achieved 5

Radiologic Imaging Role

Multiphase CT (noncontrast, late arterial, and venous phases) is used in evaluation of patients with overt GIB when endoscopy is non-diagnostic or unavailable. 1

• CT angiography can identify active bleeding and guide interventional radiology procedures 1
• Video capsule endoscopy may be used if bleeding site is suspected below the ligament of Treitz 1

Endoscopic Management

For Peptic Ulcer Disease with High-Risk Stigmata

Endoscopic hemostasis is indicated for high-risk lesions; clips or thermocoagulation, alone or with epinephrine injection, are effective methods. 1

Critical guideline:

• Epinephrine injection alone is NOT recommended 1
• Combination therapy (mechanical or thermal plus epinephrine) is superior to epinephrine monotherapy 1
• Over-the-scope clips (OTSCs) and TC-325 powder spray should be performed for high-risk stigmata 6

Clot Management

Data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. 1

For Variceal Bleeding

Treatment should be customized by severity and anatomic location. 6

• Variceal band ligation is preferred for esophageal varices 8
• Cyanoacrylate injection for gastric varices 8

Second-Look Endoscopy

Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended. 1

• For rebleeding, initial evaluation should be with repeat endoscopy 6

Post-Endoscopic Management

High-Risk Peptic Ulcer Disease

After successful endoscopic hemostasis, intravenous high-dose PPI therapy for 72 hours decreases both rebleeding and mortality in patients with high-risk stigmata. 1

Hospitalization duration:

• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
• Selected low-risk patients can be discharged promptly after endoscopy 1

Nutritional Support

Early enteral feeding should be initiated for all UGIB patients. 6

For Variceal Bleeding

High-risk patients or those with further bleeding should be considered for transjugular intrahepatic portosystemic shunt (TIPS). 6

Secondary Prevention and Long-Term Management

NSAID Users

For patients with UGIB who require a nonsteroidal anti-inflammatory drug, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding. 1

Cardiovascular Prophylaxis

Patients with UGIB who require secondary cardiovascular prophylaxis should restart acetylsalicylic acid (ASA) as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days). 1

• ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 1

Interventional Radiology and Surgical Management

Second-Line Interventions

Several radiologic interventions are now commonly used as second-line intervention after failed endoscopy. 5

• Angiographic embolization for persistent bleeding 5

Surgical Indications

Surgical intervention is indicated when acute ongoing bleeding occurs and the endovascular approach is unsuccessful. 3

• Surgery is also indicated when bleeding is associated with infected pancreatic necrosis 3

Complications and Prognostic Factors

Immediate Complications

Common complications occurring after UGIB in cirrhotic patients include:

• Hepatic encephalopathy (31.4% of attacks) 9
• Spontaneous bacterial peritonitis (18%) 9
• Renal impairment (13.2%) 9
• Rebleeding (7.8%) 9

Mortality Predictors

Independent predictors of mortality include packed red blood cell units transfused, Child-Pugh score, MELD score, and presence of hepatocellular carcinoma. 9

Specific mortality rates by etiology:

• 6-week mortality rate: 17.4% 4
• 6-week rebleeding rate: 7.2% 4
• Complications followed 78.4% of bleeding from gastric varices 9
• Complications followed only 10.8% of peptic ulcer bleeding 9

Prognostic Scoring Systems

High Child-Pugh, MELD, and ALBI scores beside the presence of HCC predict poor outcome of UGIB. 9

• In the absence of these risk factors, early discharge could be considered if the source is peptic ulcer or telangiectasia 9

Special Populations

Patients with Cirrhosis and Liver Disease

Variceal bleeding was the most common cause of UGIB at emergency presentation in cirrhotic populations (33.3%). 4

Management modifications:

• Prophylactic antibiotics are mandatory 6
• Vasoactive medications should be started immediately 6
• Higher complication rates: 42.6% of attacks result in complications 9

ICU Patients

Stress-related mucosal disease is particularly prevalent in critically ill ICU patients with risk factors such as mechanical ventilation, coagulopathy, and renal failure. 2

• Requires multidisciplinary collaboration and team-based approach 5
• Early correction of coagulopathy is essential 5