Chapter 75: Upper Gastrointestinal Bleeding

INTRODUCTION AND EPIDEMIOLOGY

Upper GI bleeding is any GI bleeding originating proximal to the ligament of Treitz. The overall annual incidence of upper GI bleeding ranges from 39 to 172 per 100,000 in Western countries.^1-3 Difference in prevalence between countries is attributed to variations in Helicobacter pylori rates, socioeconomic conditions, and prescription patterns of ulcer-healing and ulcer-promoting medications.² Increasing age, coexistent organ system disease, and recurrent hemorrhage are factors associated with increased morbidity and mortality.³

PATHOPHYSIOLOGY

PEPTIC ULCER DISEASE

Despite a downward trend in prevalence over the past 20 years, peptic ulcer disease, which includes gastric, duodenal, esophageal, and stomal ulcers, is still considered the most common cause of upper GI bleeding.^2,4 However, the Analysis of Clinical Outcomes Research Initiative found gastric and duodenal ulcers in only 20.6% of 7822 endoscopies performed for suspected upper GI bleeding.⁴ This number is much lower than previous estimates of up to 50%.^5,6 Awareness that aspirin, NSAIDs, and smoking cause bleeding and increased recognition and treatment of H. pylori infection may be responsible for decreased incidence.^7-10

EROSIVE GASTRITIS AND ESOPHAGITIS

Erosive gastritis, esophagitis, and duodenitis are also common causes of GI hemorrhage.¹¹ Common predisposing factors include alcohol, salicylates, and NSAIDs. Infection, toxic ingestion, radiation, and stress from severe illness may also cause erosive gastritis. Stress-related mucosal disease occurs in patients with overwhelming sepsis, trauma, or respiratory failure requiring mechanical ventilation. Candida, herpes simplex virus, cytomegalovirus, and human immunodeficiency virus are potential sources of esophageal bleeding from infection.

ESOPHAGEAL AND GASTRIC VARICES

Esophageal and gastric varices result from portal hypertension and, in the United States, are most often a result of alcoholic liver disease.¹² Although varices account for a small percentage of all cases of upper GI hemorrhage, they can rebleed and carry a high mortality rate. However, many patients with end-stage cirrhosis never develop varices; many patients with documented varices never bleed; and many patients with a documented history of varices presenting with upper GI bleeding will actually bleed from nonvariceal sites. Variceal bleeding is the cause of upper GI bleeding in cirrhotics 59% of the time, followed by peptic ulcer disease in 16% of cases.¹³ In-hospital mortality rates for any type of GI bleed in cirrhotics are essentially double those of noncirrhotic patients.¹⁴

MALLORY-WEISS SYNDROME

Mallory-Weiss syndrome is bleeding secondary to a longitudinal mucosal tear at the gastroesophageal junction. The classic history is repeated vomiting followed by bright red hematemesis. The syndrome can be associated with alcoholic binge drinking, DKA, or chemotherapy administration. The Valsalva maneuver, such as from coughing or seizures, is also a reported cause.

DIEULAFOY LESIONS

Dieulafoy lesions are arteries of ...