Acute upper gastrointestinal bleed
Acute upper gastrointestinal bleeds arise from the stomach, duodenum and oesophagus.
50–150 per 100,000 population per year.
The most common cause is peptic ulcer disease (35– 50%) often exacerbated by the use of nonsteroidal anti-inflammatory drugs.
Acute gastroduodenal erosions can follow any major illness (8–15%).
Mallory Weiss tears of the oesophagus resulting from vomiting (15%).
Oesophageal varices may cause torrential bleeding (5– 10%).
Rarer causes include upper gastrointestinal malignancy and vascular malformations.
Haematemesis is vomiting of blood. It may appear fresh red or as ‘coffee ground’ altered blood. Melaena is the passage of black tarry stool due to at least 50 mL of digested blood; however, if there is very fast gut transit time or rapid bleeding, bright red blood may be passed rectally. It is essential to identify any coexistent medical conditions especially renal or liver disease and those with widespread malignancy, as these patients (along with the elderly) are at greatest risk of mortality.
Urgent full blood count, U & Es, LFTs, coagulation screen and cross match specimens should be sent. The haemoglobin level may not be low despite severe blood loss until fluid redistribution or resuscitation has occurred.
The initial management is to correct fluid loss and hypotension. All patients require large bore cannulae ideally in the anterior antecubital fossae. A central line may also be necessary for measurement of the central venous pressure. If the patient is in a state of shock they should be catheterised for accurate hourly fluid balance. Any coagulopathies should be corrected, e.g. with vitamin K and fresh frozen plasma.
· Young patients with minor bleeds and no comorbidity should be observed and undergo an elective endoscopy.
· Patients with more severe bleeding, particularly older patients or those with comorbidity, require urgent endoscopic assessment and therapy after adequate resuscitation.
· In non-variceal bleeding failure of endoscopic therapy or further bleeding after a second endoscopic treatment is an indication for surgery.
Ninety per cent of haemorrhages originating from peptic ulcers will stop spontaneously. Indicators of poor prognosis and recurrent bleeds:
· Haematemesis and melaena together. Age over 60 years.
· Shock (pulse >100 and systolic BP <100 mmHg). Comorbidity (including obesity).
· Young patient with postural drop >20 mmHg.