Upper Gastrointestinal Bleeding - Causes, Symptoms, and Treatment

Introduction

Upper gastrointestinal bleeding is the most common gastrointestinal emergency. It accounts for 50 to 170 hospital admissions per year. The mortality rate for hospital admission is about 10 %. According to the location of gastrointestinal bleeding, the bleeding can be either upper or lower gastrointestinal bleeding. Lower gastrointestinal bleeding is from the small and large intestines (colon), rectum, and anus.

The common causes of acute upper gastrointestinal bleeding are esophagitis, peptic ulcer, varices, cancer of the stomach, and liver cirrhosis. In addition, patients with upper gastrointestinal bleeding suffer from rectal bleeding, dark stools, and vomiting blood. Treatment of upper gastrointestinal bleeding depends on the source of bleeding; severe bleeding can be life-threatening. This article describes the types, causes, and treatment of upper gastrointestinal bleeding.

What Is Upper Gastrointestinal Bleeding?

Upper gastrointestinal bleeding refers to bleeding from the esophagus, duodenum, and stomach. Upper gastrointestinal bleeding can be acute, occult, and obscure. It is diagnosed through various tests and investigations. It is helpful to distinguish those patients who present with profuse, acute bleeding from those who give chronic or subacute bleeding or lesser severity.

What Are the Sources of Upper Gastrointestinal Bleeding?

Upper gastrointestinal bleeding is divided into three parts:

• Acute Upper Gastrointestinal Hemorrhage - It can be due to bleeding from the esophagus, stomach, and duodenum.

• Chronic Occult Gastrointestinal Bleeding - In this context, occult means that the blood or its breakdown product is present in this stool but cannot be observed with the naked eye. Occult bleeding can cause iron deficiency anemia, as bleeding can reach 200 ml (milliliter) per day. Colorectal cancer, particularly cancer of the caecum, may produce no gastrointestinal symptoms and is the most important cause of gastrointestinal bleeding.

• Major Gastrointestinal Bleeding of Unknown Cause - In some patients with major gastrointestinal bleeding, upper endoscopy and colonoscopy fail to reveal a diagnosis. When severe life-threatening bleeding continues, urgent computed tomography mesenteric angiography is indicated. This investigation usually identifies the site if the bleeding rate exceeds 1 ml per minute.

What Causes Upper Gastrointestinal Bleeding?

The following are the causes of upper gastrointestinal bleeding;

• Esophagitis - The inflammation of the esophagus is called esophagitis. It accounts for 10 percent, causing upper gastrointestinal bleeding, usually with hiatus hernia.

• Peptic Ulcer - An ulcer in the lining of the lower esophagus, stomach, or duodenum. A peptic ulcer is a chronic condition. It accounts for 35 percent to 50 percent causing upper gastrointestinal bleeding.

• Vascular Malformation - An blood or lymph vessel abnormality.

• Aorto-Duodenal Fistula - The pathological connection between the aorta and duodenum. It rarely causes upper gastrointestinal bleeding but may be overlooked.

• Varices - Gastric varices are dilated veins found in the lining of the stomach, which can be a complication of liver cirrhosis and life-threatening.

• Mallory-Weiss Tear - Bleeding from the esophagus or stomach mucosal laceration.

• Cancer of the Stomach or Esophagus - Tumor cells in the esophagus and stomach.

• Gastric Erosions - Inflammation of the stomach lining due to intake of alcohol or non-steroidal anti-inflammatory drugs.

What Are the Signs and Symptoms of Upper Gastrointestinal Bleeding?

The following are the symptoms of upper gastrointestinal bleeding:

• Hematemesis - Vomiting blood is red with a clot when bleeding is rapid and profuse or black when less severe.

• Syncope may occur, and it is caused by low blood pressure.

• Anemia (low hemoglobin in blood).

• Melaena (passage of black and tarry stool containing blood).

• Maroon or bright red stool.

• Lightheadedness.

• Difficulty breathing.

• Fainting.

• Chest pain.

• Abdominal pain.

• Upper abdominal discomfort.

• Weakness.

• Fatigue.

• Loss of appetite.

Signs:

• Low blood pressure.

• Tachycardia (fast heart rate).

• Oliguria (low urine output).

• Anemia (low hemoglobin).

• Cold and sweating.

When Should the Doctor Be Consulted?

If a person suffers from upper gastrointestinal bleeding, they should immediately contact a doctor. If the bleeding is severe, a hospital stay will be required. It can be a life-threatening condition and need immediate medical emergency. If bleeding is mild, over-the-counter drugs may help but should be taken only with the doctor's recommendation. In addition, a person should consult a doctor immediately if they see any of the following:

• Vomiting blood.

• Black stool.

• Blood in the stool.

What Investigations Are Done to Diagnose Upper Gastrointestinal Bleeding?

Diagnosis of upper gastrointestinal bleeding is made by taking a proper patient's history. Initially, the patient should be checked for signs of upper gastrointestinal bleeding like tachycardia, hypotension, and oliguria. The patient may be suffering from a cold. The doctor may ask for a few tests to seek evidence of liver disease or the presence of respiratory or renal disease. It is essential to rule them out as these may be worsened by acute bleeding. They also increase endoscopy and surgical risk factors. Following are the basic investigations for upper gastrointestinal bleeding:

1. Blood Test - Full blood count Is helpful as chronic or sub-acute bleeding leads to anemia. Low hemoglobin levels in the blood indicate anemia. A deficiency of platelets in the blood may be a clue to the presence of an enlarged spleen in chronic liver disease.

2. Urea and Electrolyte Test - This test may show evidence of kidney failure. The blood urea rises as the absorbed product of the blood is metabolized by the liver and is indicative of severe bleeding.

3. Liver Function Test - These may show evidence of chronic liver disease.

4. Prothrombin Time - It helps to check when there is a clinical suggestion of liver disease or if the patient is anticoagulated.

5. X-ray- It helps to detect the source of gastrointestinal bleeding.

6. Endoscopy- Ideally done within 24 hours, yielding a diagnosis in 80% of cases.

What Is the Treatment for Upper Gastrointestinal Bleeding?

After initial clinical assessment and basic investigations, a treatment course for upper gastrointestinal bleeding is decided. The presence of two or more diseases in a patient concurrently should be managed appropriately. Treatment options for upper gastrointestinal bleeding are:

1. Medication : Proton pump inhibitor therapy treats patients with upper gastrointestinal bleeding. Patients should be given broad-spectrum antibiotics if suspected of chronic liver disease.

2. Blood Transfusion :

• The first step is to gain intravenous access using at least one large bore cannula and at least two units of cross-matched blood if a significant bleed is suspected.

• Blood should be transfused after cross-matching in patients with blood pressure drops and high heart rates due to profuse bleeding.

• Intravenous fluid should be given to raise blood pressure.

3. Oxygen : This should be given to all patients in shock.

4. Endoscopy : This should be carried out after adequate blood transfusion and intravenous fluids. Patients with major endoscopic stigmata of the recent hemorrhage can be treated endoscopically combined with the injection of Adrenaline into the bleeding point. A biological inert hemostatic mineral powder can be used as rescue therapy when standard therapy fails. Patients suffering from variceal bleeding are treated with band ligation. If this fails, balloon tamponade is another option, while arrangements are made for a transjugular, intrahepatic portosystemic shunt (TIPSS).

• When endoscopic hemostasis (arrest of bleeding) fails to active bleeding, and if bleeding starts again after four or five days, surgery can be opted. Angiographic embolization is an effective alternative to surgery in weaker patients. The choice of operation depends on the site and diagnosis of the bleeding lesion. Local excision may be performed, but partial gastrectomy (partial stomach removal) is required when neither is possible.

5. Eradication : Those patients who test positive for Helicobacter pylori infection should receive eradication therapy. A urea breath test or fecal antigen testing should confirm successful eradication.

Conclusion

Gastrointestinal bleeding can be life-threatening, so it should not be ignored. If gastrointestinal bleeding is left untreated, it can cause severe complications such as heart attack, unconsciousness, shock, and even death. It is always best to seek help from a healthcare professional. Patients should regularly visit their doctor to get their vitals monitored. People can prevent upper gastrointestinal bleeding by limiting the overuse of the non-steroidal anti-inflammatory drug (NSAIDs), Aspirin, and alcohol intake. If you smoke, then it is better to quit always.