Abstract
Upper gastrointestinal bleeding (UGIB) is a life-threatening condition that accounts for a significant number of hospitalizations, leading to considerable morbidity, mortality, and resource utilization. UGIB has a multitude of causes, with peptic ulcer disease and varices being the most common, and disproportionately affects the elderly with a higher mortality among these patients. The majority of UGIB patients do not require intervention; therefore, identifying patients at risk of rebleeding or mortality is the goal. Aggressive resuscitation and timely endoscopy for localization of the bleeding source are paramount to identify patients who do not stop bleeding and may require endoscopic, surgical, or angiographic intervention.
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References
Zhao Y, Encinosa W. Hospitalizations for gastrointestinal bleeding in 1998 and 2006: statistical brief #65. Healthcare Cost and Utilization Project (HCUP) statistical briefs [Internet]. Rockville: Agency for Healthcare Research and Quality (US); 2006-2008.
Silverstein FE, Gilbert DA, Tedesco FJ, Buenger NK, Persing J. The national ASGE survey on upper gastrointestinal bleeding. I. Study design and baseline data. Gastrointest Endosc. 1981;27(2):73–9. No abstract available.
Abougergi MS, Travis AC, Saltzman JR. Impact of day of admission on mortality and other outcomes in upper GI hemorrhage: a nationwide analysis. Gastrointest Endosc. 2014;80(2):228–35.
Rosenstock SJ, Moller MH, Larsson H, Johnsen SP, Madsen AH, Bendix J, et al. Improving quality of care in peptic ulcer bleeding: nationwide cohort study of 13,498 consecutive patients in the Danish Clinical Register of Emergency Surgery. Am J Gastroenterol. 2013;108(9):1449–57.
Loffroy R, Estivalet L, Cherblanc V, Sottier D, Guiu B, Cercueil JP, et al. Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding. World J Gastrointest Surg. 2012;4(10):223–7.
Abougergi MS, Travis AC, Saltzman JR. The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis. Gastrointest Endosc. 2015;81(4):882–8.
Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1995;90(2):206–10.
Sreedharan A, Martin J, Leontiadis G, Doward S, Howden CW, Forman D, et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;7:CD005415.
Al-Sabah S, Barkun AN, Herba K, Adam V, Fallone C, Mayrand S, et al. Cost-effectiveness of Proton-pump inhibition before endoscopt in upper gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2008;6(4):418–25.
Cheng HC, Wu CT, Chang WL, Cheng WC, Chen WY, Sheu BS. Double oral esomeprazole after a 3-day intravenous esomeprazole infusion reduces recurrent peptic ulcer bleeding in high-risk patients: a randomised controlled study. Gut. 2014;63(12):1864–72.
Morrison CA, Carrick MM, Norman MA, Scott BG, Welsh FJ, Tsai P, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma. 2011;70(3):652–63.
Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345–60; quiz 361.
Baradarian R, Ramdhaney S, Chapalamadugu R, Skoczylas L, Wang K, Rivilis S, et al. Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases mortality. J Gastroenterol. 2004;99(4):619–22.
Siegal DM, Konkle BA. What is the effect of rivaroxaban on routine coagulation tests? Hematology Am Soc Hematol Educ Program. 2014;2014(1):334–6.
Blasi A, Beltran J, Pereira A, Martinez-Palli G, Torrents A, Balust J, et al. An assessment of thromboelastometry to monitor blood coagulation and guide transfusion support in liver transplantation. Transfusion. 2012;52(9):1989–98.
Black DAK, Powell JF. Absorption of haemoglobin iron. Biochem J. 1942;36(1-2):110–2.
Ernst AA, Haynes ML, Nick TG, Weiss SJ. Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding. Am J Emerg Med. 1999;17(1):70–2.
Richards RJ, Donica MB, Grayer D. Can the blood urea nitrogen/creatinine ratio distinguish upper from lower gastrointestinal bleeding? J Clin Gastroenterol. 1990;12(5):500–4.
Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M. ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis. Am J Emerg Med. 2006;24(3):280–5.
Jairath V, Kahan BC, Stanworth SJ, Logan RF, Hearnshaw SA, Travis SP, Palmer KR, Murphy MF. Prevalence, management, and outcomes of patients with coagulopathy after acute nonvariceal upper gastrointestinal bleeding in the United Kingdom Transfusion. 2013;53(5):1069–76. doi: https://doi.org/10.1111/j.1537-2995.2012.03849.x. Epub 2012 Aug 15.
Razzaghi A, Barkun AN. Platelet transfusion threshold in patients with upper gastrointestinal bleeding: a systematic review. J Clin Gastroenterol. 2012;46(6):482–6.
Hickey M, Gatien M, Taljaard M, Aujnarain A, Giulivi A, Perry JJ. Outcomes of urgent warfarin reversal with frozen plasma versus prothrombin complex concentrate in the emergency department. Circulation. 2013;128(4):360–4.
Refaai MA, Goldstein JN, Lee ML, Durn BL, Milling TJ Jr, Sarode R. Increased risk of volume overload with plasma compared with four-factor prothrombin complex concentrate for urgent vitamin K antagonist reversal. Transfusion. 2015;55(11):2722–9.
Fawole A, Daw HA, Crowther MA. Practical management of bleeding due to anticoagulants dabigatran, rivaroxaban, and apixaban. Cleve Clin J Med. 2013;80(7):443–51.
Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015;47(10):a1–46.
Hearnshaw SA, Logan RF, Lowe D, Travis SP, Murphy MF, Palmer KR. Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit. Gut. 2010;59(8):1022–9.
Bethea ED, Travis AC, Saltzman JR. Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding. J Clin Gastroenterol. 2014;48(10):823–9.
Wysocki JD, Srivastav S, Winstead NS. A nationwide analysis of risk factors for mortality and time to endoscopy in upper gastrointestinal haemorrhage. Aliment Pharmacol Ther. 2012;36:30–6.
Tsoi KKF, Ma TKW, Sung JJY. Endoscopy for upper gastrointestinal bleeding: how urgent is it? Nat Rev Gastroenterol Hepatol. 2009;6:463–9.
Park SJ, Park H, Lee YC, Choi CH, Jeon TJ, Park JC, et al. Effect of scheduled second-look endoscopy on peptic ulcer bleeding: a prospective randomized multicenter trial. Gastrointest Endosc. 2017. pii: S0016-5107(17)32117-X. doi: https://doi.org/10.1016/j.gie.2017.07.024. [Epub ahead of print].
Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage. BMJ. 1995;311:222–6.
Vreeburg EM, Snel P, de Bruijne JW, Bartelsman JF, Rauws EA, Tytgat GN. Acute upper gastrointestinal bleeding in the Amsterdam area: incidence, diagnosis, and clinical outcome. Am J Gastroenterol. 1997;92:236–43.
Enestvedt BK, Graknek IM, Mattek N, Lieberman DA, Eisen G. An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium. Gastrointest Endosc. 2008;67(3):422–9.
Kim JJ, Sheibani S, Park S, Buxbaum J, Laine L. Causes of bleeding and outcomes in patients hospitalized with upper gastrointestinal bleeding. J Clin Gastroenterol. 2014;48(2):113–8.
Freeman ML. Stigmata of hemorrhage in bleeding ulcers. Gastrointest Endosc Clin N Am. 1997;7(4):559–74.
Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med. 1994;331(11):717–27.
Wara P. Endoscopic prediction of major rebleeding—a prospective study of stigmata of hemorrhage in bleeding ulcer. Gastroenterology. 1985;88(5 Pt 1):1209–14.
Mendelson AH, Donowitz M. Catching the zebra: clinical pearls and pitfalls for the successful diagnosis of Zollinger-Ellison syndrome. Dig Dis Sci. 2017;62(9):2258–65. https://doi.org/10.1007/s10620-017-4695-7. Epub 2017 Aug 3.
Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet. 1974;2(7877):394–7.
Bratanic A, Puljiz Z, Ljubicicz N, Caric T, Jelicic I, Pulkiz M, et al. Predictive factors of rebleeding and mortality following endoscopic hemostasis in bleeding peptic ulcers. Hepatogastroenterology. 2013;60:112–7.
Sánchez-Delgado J, Gené E, Suárez D, et al. Has H. pylori prevalence in bleeding peptic ulcer been underestimated? A meta-regression. Am J Gastroenterol. 2011;106:398–405.
Barkun AN, Moosavi S, Martel M. Topical hemostatic agents: a systematic review with particular emphasis on endoscopic application in GI bleeding. Gastrointest Endosc. 2013;77:692–700.
Prachayakul V, Aswakul P, Chantarojanasiri T, Leelakusolvong S. Factors influencing clinical outcomes of Histoacryl® glue injection-treated gastric variceal hemorrhage. World J Gastroenterol. 2013;19(15):2379–87. https://doi.org/10.3748/wjg.v19.i15.2379. Published online 2013 Apr 21.
Lee YJ, Min BR, Kim ES, Park KS, Cho KB, Jang BK, et al. Predictive factors of mortality within 30 days in patients with nonvariceal upper gastrointestinal bleeding. Korean J Intern Med. 2016;31(1):54–64. https://doi.org/10.3904/kjim.2016.31.1.54. Published online 2015 Dec 28.
Napolitano L. Refractory peptic ulcer disease. Gastroenterol Clin North Am. 2009;38(2):267–88.
Lee CW, Sarosi GA Jr. Emergency ulcer surgery. Surg Clin North Am. 2011;91(5):1001–13.
Brown DP. Gastric packing in the control of massive gastroduodenal hemorrhage. Am J Gastroenterol. 1970;54(1):49–51.
Cortese F, Colozzi S, Marcello R, Muttillo IA, Giacovazzo F, Nardi M, et al. Gastroduodenal major haemorrhages in critical patients: an original surgical technique. Am Ital Chir. 2013;84(6):671–9.
White RI Jr, Harrington DP, Novak G, Miller FJ Jr, Giargiana FA Jr, Sheff RN. Pharmacologic control of hemorrhagic gastritis: clinical and experimental results. Radiology. 1974;111(3):549–57.
Millat B, Hay JM, Valleur P, et al. Emergency surgical treatment for bleeding duodenal ulcer: oversewing plus vagotomy versus gastric resection, a controlled randomized trial. French Associations for Surgical Research. World J Surg. 1993;17(5):568–73. discussion 574.
Sugawa C, Steffes CP, Nakamura R, Sferra JJ, Sferra CS, Sugimura Y, et al. Upper GI bleeding in an urban hospital. Etiology, recurrence, and prognosis. Ann Surg. 1990;212(4):521–6; discussion 526-7.
Zimmerman J, Shohat V, Tsvang E, Arnon R, Safadi R, Wengrower D. Esophagitis is a major cause of upper gastrointestinal hemorrhage in the elderly. Scand J Gastroenterol. 1997;32(9):906–9.
Owen DA. Gastritis and carditis. Mod Pathol. 2003;16(4):325–41.
Czaja AJ, McAlhany JC, Pruitt BA Jr. Acute gastroduodenal disease after thermal injury. An endoscopic evaluation of incidence and natural history. N Engl J Med. 1974;291(18):925–9.
Martin LF. Gastrointestinal bleeding in critically ill patients. N Engl J Med. 1994;331(1):51–2; author reply 52-3.
Goldman MS Jr, Rasch JR, Wiltsie DS, Finkel M. The incidence of esophagitis in peptic ulcer disease. Am J Dig Dis. 1967;12(10):994–9.
Barletta JF, Mangram AJ, Sucher JF, Zach V. Stress ulcer prophylaxis in neurocritical care. Neurocrit Care. 2017; https://doi.org/10.1007/s12028-017-0447-y. [Epub ahead of print].
Peura DA, Johnson LF. Cimetidine for prevention and treatment of gastroduidenalmuscosal lesions in patients in an intensive care unit. Ann Intern Med. 1985;103(2):173–7.
Schuster DP, Rowley H, Feinstein S, McGue MK, Zuckerman GR. Prospective evaluation of the risk of upper gastrointestinal bleeding after admissions to a medical intensive care unit. Am J Med. 1984;76(4):623–30.
Zuckerman GR, Shuman R. Therapeutic goals and treatment options for prevention of stress ulcer syndrome. Am J Med. 1987;83(6A):29–35.
Cook DJ, Reeve BK, Scholes LC. Histamine-2-receptor antagonists and antacids in the critically ill population: stress ulceration versus nosocomial pheumonia. Infect Control Hosp Epidemiol. 1994;15(7):437–42.
Sugawa C, Benishek D, Walt AJ. Mallory-Weiss syndrome. A study of 224 patients. Am J Surg. 1983;145(1):30–3.
Lee YT, Walmsley RS, Leong RW, Sung JJ. Dieulafoy’s lesion. GastrointestvEndosc. 2003;58(2):236–43.
Juler GL, Labitzke HG, Lamb R, Allen R. The pathogenesis of Dieulafoy’s gastric erosion. Am J Gastroenterol. 1984;79(3):195–200.
Norton ID, Petersen BT, Sorbi D, Balm RK, Alexander GL, Gostout CJ. Management and long-term prognosis of Dieulafoylesion. Gastrointest Endosc. 1999;50(6):762–7.
Cathcart S, Birk JW, Tadros M, Schuster MJ. Hemobilia: an uncommon but notable cause of upper gastrointestinal bleeding. Clin Gastroenterol. 2017;51(9):796–804.
Camus M, Jensen DM, Ohning GV, Kovacs TO, Ghassemi KA, Jutabha R, et al. Severe upper gastrointentestinal hemorrhage from linear gastric ulcers in large hiatal hernias: a large prospective case series of Cameron ulcers. Endoscopy. 2013;45(5):397–400.
Gray DM, Kushnir V, Kalra G, Rosenstock A, Alsakka MA, Patel A, et al. Cameron lesions in patients with hiatal hernias: prevalence, presentation, and treatment outcome. Dis Esophagus. 2015;28(5):448–52.
Berzigotti A, Bosch J, Boyer TD. Use of noninvasive markers of portal hypertension and timing of screening endoscopy for gastroesophageal varices in patients with chronic liver disease. Hepatology. 2014;59(2):729–31.
Merli M, Nicolini G, Angeloni S, et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol. 2003;38:266–72.
Carbonell N, Pauwels A, Serfaty L, Fourdan O, Lévy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology. 2004;40(3):652–9.
Reverter E, Tandon P, Augustin S, Turon F, Casu S, Bastiampillai R, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology. 2014;146(2):412–9. e3.
Stiegmann GV, Goff JS, Michaletz-Onody PA, Korula J, Lieberman D, Saeed ZA, et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N Engl J Med. 1992;326(23):1527–32.
Villanueva C, Piqueras M, Aracil C, et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. 2006;45:560–7.
Sengstaken RW, Blakemore AH. Balloon tamponage for the control of hemorrhage from esophageal varices. Ann Surg. 1950;131:781–9.
Wright G, Lewis H, Hogan B, et al. A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc. 2010;71:71–8.
D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology. 1995;22(1):332–54.
Yoshida H, Mamada Y, Taniai N, Yoshioka M, Hirakata A, Kawano Y, et al. Treatment modalities for bleeding esophagogastric varices. J Nippon Med Sch. 2012;79(1):19–30.
Lin CT, Huang TW, Lee SC, et al. Sengstaken-Blakemore tube related esophageal rupture. Rev Esp Enferm Dig. 2010;102:395–6.
García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al.; Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group. Early use of TIPS in patients with cirrhosis and variceal bleeding. Am Surg. 1990;56(12):758–63.
Evans GR1, Yellin AE, Weaver FA, Stain SC. Sinistral (left-sided) portal hypertension. N Engl J Med. 2010;362(25):2370–9.
Grady E. Gastrointestinal bleeding scintigraphy in the early 21st century. J Nucl Med. 2016;57(2):252–9. https://doi.org/10.2967/jnumed.115.157289. Epub 2015 Dec 17.
Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding. J Med Imaging Radiat Oncol. 2008;52(4):333–8.
Gaba RC. Transjugular intrahepatic portosystemic shunt creation with embolization or obliteration for variceal bleeding. Tech Vasc Interv Radiol. 2016;19(1):21–35.
Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al.; International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101–13.
Abougergi MS, Avila P, Saltzman JR. Impact of insurance status and race on outcomes in nonvariceal upper gastrointestinal hemorrhage: a nationwide analysis. J Clin Gastroenterol. 2017; https://doi.org/10.1097/MCG.0000000000000909. [Epub ahead of print].
Berne CJ, Tosoff L. Peptic ulcer perforation of the gastroduodenal artery complex: clinical features and operative control. Ann Surg. 1969;169(1):141–4.
Shin JH. Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol. 2012;13(Suppl1):S31–9.
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Tafen, M., Stain, S.C. (2019). Upper Gastrointestinal Bleeding. In: Brown, C., Inaba, K., Martin, M., Salim, A. (eds) Emergency General Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-96286-3_7
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