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Gastrointestinal bleeding is an important cause of mortality for emergency department (ED) and critical care patients. This chapter discusses the two major types of bleeding, upper and lower, followed by detailed information on the management of these difficult patients.
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Upper gastrointestinal bleeding (UGIB) is an important cause of mortality in the ED with rates from 3% to 16%.1–7 In the United States, UGIB represents 400,000 hospital admissions8 and 30,000 deaths annually.9 Hospital in-patients presenting with UGIB have a 2- to 6-fold increase of mortality compared with their ED counterparts.1–7 Increased risk of mortality is associated with increased age, severe comorbidity, hypotension, shock, rebleeding, and the timing of the bleeding event during an in-patient hospital stay.2,10
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Clinical Presentation
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Patients with UGIB often present with hematemesis, coffee ground vomiting, melena, or maroon stool, while hematochezia is typically associated with massive hemorrhage. The presentation of bleeding depends on the amount and location of hemorrhage. Patients may present with complications of anemia, including fatigue, chest pain, syncope, and shortness of breath. Untreated manifestations of progressive hemorrhagic shock are inevitable, including acute end-organ dysfunction and refractory hypotension.
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The physical exam should include an assessment of airway, vital signs, and mentation. An abdominal exam, if tenderness is elicited, aids in localizing the source to a gastric or duodenal location. Blood on digital rectal exam may suggest both chronicity and degree of bleeding. The absence of rectal blood, however, does not exclude the existence of a gastrointestinal source. Stigmata of chronic liver disease including jaundice, telangiectasia, hemorrhoids, or caput medusae may indicate the presence of esophageal or gastric varices.
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UGIB can originate from a number of sources and are discussed below in order of frequency. A list of causes of upper GI bleeding is listed in Table 19-1.
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Despite the advent of H2 receptor antagonists and proton pump inhibitors (PPIs), peptic ulcer disease (PUD) remains the most common etiology of UGIB accounting for 140,000 hospitalizations each year in the United States.11 Approximately 28–59% of UGIB is represented by PUD, with the majority of duodenal, as opposed to gastric, origin.1,12 GI bleeding from a duodenal location is fairly common owing to its abundant blood supply and the posterior location of the gastroduodenal artery to the bulb. This is the case with most massive UGIBs. The presence of large ulcers in the posterior duodenal bulb or on the lesser curvature of the stomach ...