Ask about hematemesis, coffee-ground emesis, or melena. Classically, hematemesis and coffee-ground emesis suggest a UGI source. The presence of melena and age <50 years old more likely indicate an upper GI bleed versus a lower GI bleed, even in patients without hematemesis.16 Vomiting and retching, followed by hematemesis, suggest a Mallory-Weiss tear. Be sure to ask about prior episodes of GI bleeding and any interventions performed. A history of an aortic graft should suggest bleeding from an aortoenteric fistula. Review the patient's medication list carefully. Salicylates, glucocorticoids, NSAIDs, and anticoagulants all place the patient at high risk for GI bleed. Alcohol abuse is strongly associated with a number of causes of bleeding, including peptic ulcer disease, erosive gastritis, and esophageal varices. Ingestion of iron or bismuth can simulate melena. Liquid medications with red dye, as well as certain foods, such as beets, can simulate hematochezia. In such cases, stool guaiac testing will be negative. Inquire about past history of GI bleeding, even though recurrent bleeding episodes may originate from different sources.
Although the medical history may suggest the source of bleeding, history can also be misleading. For instance, what initially appears to be lower GI bleeding may actually be a UGI bleed in disguise. Bright red or maroon rectal bleeding unexpectedly originates from UGI sources about 14% of the time.16 Although patients volunteer complaints of hematemesis or melena, if there is no vomiting or the patient has not noted tarry stools, signs may be subtle. Patients with hypotension, tachycardia, angina, syncope, weakness, confusion, or cardiac arrest may have underlying GI hemorrhage.
Visual inspection of the vomitus for a bloody, maroon, or coffee-ground appearance is the most reliable way to diagnose UGI bleeding in the ED. Consider keeping a sample of the vomitus or nasogastric (NG) aspirate at bedside for the gastroenterologist to view.
Vital signs may reveal obvious hypotension and tachycardia or more subtle findings such as decreased pulse pressure or tachypnea. Younger patients and those without comorbidities can tolerate substantial volume loss with minimal or no changes in vital signs. Paradoxical bradycardia may occur even in the face of profound hypovolemia. Remember that comorbid conditions and medications may mask the body's physiologic response to volume loss. β-Blockers, for example, will prevent tachycardia. Patients with baseline hypertension may have relatively normal blood pressure in the setting of hypovolemia.
Cool, clammy skin is an obvious sign of shock. Spider angiomas, palmar erythema, jaundice, and gynecomastia suggest liver disease. Petechiae and purpura suggest an underlying coagulopathy. Facial lesions, cutaneous macules, or telangiectasias may be suggestive of the Peutz-Jeghers, Rendu-Osler-Weber, or Gardner's syndromes. A careful ear, nose, and throat examination can reveal an occult bleeding source that has resulted in swallowed blood and subsequent coffee-ground emesis. Abdominal examination may disclose tenderness, masses, ascites, or organomegaly.
Perform rectal examination to detect the presence of blood and its appearance, whether bright red, maroon, or melanotic.
In patients with significant bleeding, the single most important laboratory test is to obtain blood for type and cross-match in case transfusion is needed. A CBC is also important, although the initial hematocrit level may not reflect the actual amount of acute blood loss. In addition, consider BUN, creatinine, electrolyte, glucose, coagulation, and liver function studies. UGI hemorrhage will elevate BUN levels through digestion and absorption of hemoglobin. A BUN:creatinine ratio ≥30 suggests a UGI source of bleeding.17 Coagulation studies, including INR, partial thromboplastin time, and platelet count, are useful in patients taking anticoagulants and those with underlying hepatic disease. Obtain an ECG in patients with underlying coronary artery disease. Silent cardiac or mesenteric ischemia can develop if bleeding decreases cardiac or mesenteric perfusion. A single elevated lactate level is a sentinel sign of severe illness. The success or failure of resuscitation efforts can be assessed by following dynamic lactate levels, because a rising lactate level in the hospital setting is a clear predictor of in-hospital mortality.18
Routine abdominal and chest radiographs are of limited value and are not needed in the absence of specific clinical indications. Barium contrast studies are contraindicated because barium may hinder subsequent endoscopy or angiography.
In cases where traditional endoscopy is unavailable or endoscopic visualization is unable to find the source, consider tagged red-cell scintigraphy or visceral angiography. Both of these tests will demonstrate the source only in cases of active bleeding. Scintigraphy and angiography help localize the source of bleeding to determine whether medical or surgical management is optimal.
NG intubation and aspiration are diagnostic and therapeutic.19 In patients without a history of hematemesis, a positive aspirate provides strong evidence for a UGI source of bleeding. High-risk lesions are more likely in patients with bloody aspirates. Visual inspection of the aspirate to identify bloody, maroon, or coffee-ground material verifies UGI bleeding. Early NG lavage is associated with decreased time to endoscopy.20 NG tube placement and lavage can confirm the diagnosis of UGI bleeding and stratify risk.
A negative NG aspirate does not conclusively exclude a UGI source. Intermittent bleeding, pyloric spasm, or edema preventing reflux of duodenal blood can cause false-negative results. Ultimately, NG aspiration yields a positive result in only 23% of patients without hematemesis who have occult UGI bleeding.21
Guaiac testing of NG aspirate can yield both false-negative and false-positive results. Conventional stool guaiac cards may be falsely negative. However, guaiac cards specifically designed for UGI sources are available. Conversely, even minimally traumatic NG intubation can result in positive guaiac testing even in the face of a clear aspirate. Visual inspection of the aspirate for a bloody, maroon, or coffee-ground appearance is the most reliable way to diagnose UGI bleeding in the ED.
If bright red blood or clots are found in the NG aspirate, perform gentle gastric lavage. Room temperature water is the preferred irrigant. Maintain the NG tube on mild, intermittent suction. Suction that is too vigorous may produce gastric erosions that can confuse findings on subsequent endoscopy.
As of this writing, there is no evidence to support concerns that NG tube passage may provoke bleeding in patients with varices.
Risk stratification depends on clinical judgment. There are no universally accepted pre-endoscopy risk stratification practice guidelines. However, the literature does seem to agree on those individuals that qualify as very low risk (Table 75–1). Pre-endoscopic predictors of higher risk include advanced age, comorbidities, red hematemesis, hematochezia, red blood on NG aspirate, hemodynamic instability, and abnormal laboratory studies.22,23,24,25,26 Other high-risk factors include prior variceal banding, clamping or cauterization of an ulcer bed, or the transjugular intrahepatic portosystemic shunt procedure.
Upper GI Bleeding Risk
||Download (.pdf) Table 75–1
Upper GI Bleeding Risk
|Very Low Risk ||High Risk |
|<60 y old ||Advanced age |
|No major comorbidities ||Comorbidities and prior endoscopic or transjugular intrahepatic portosystemic shunt procedures |
|No history of red hematemesis ||Red hematemesis |
|No hematochezia ||Hematochezia or melena |
|Negative nasogastric (NG) aspirate ||Positive NG aspirate |
|Hemodynamically stable at ED presentation ||Hemodynamically unstable |
|Normal laboratory studies ||Abnormal laboratory studies |