What is Upper Gastrointestinal Bleeding (GI bleed)?
Upper gastrointestinal bleeding (UGIB) is a fairly common issue affecting about 80 to 150 out of 100,000 people every year. It has a fatality rate ranging from 2% to 15%. UGIB refers to any bleeding that starts from a part of the digestive system located above a certain ligament within the small intestine. The symptoms can vary and may include vomiting bright red or coffee-ground-like substances, passing bright red or black stools, or feeling faint, tired, and weak due to blood loss. UGIB can occur suddenly, be hidden, or remain mysterious.
What Causes Upper Gastrointestinal Bleeding (GI bleed)?
Upper gastrointestinal bleeding (UGIB) can be caused by various factors. Peptic Ulcer Disease (PUD), a condition where one develops ulcers in the stomach lining or the upper part of the small intestine, is responsible for about 40% to 50% of UGIB cases. Specifically, 30% of UGIB cases are due to duodenal ulcers, which are a type of PUD. Frequently, ulcers can be linked to things like overusing pain-relievers (NSAIDs), a bacteria called Helicobacter pylori, and illnesses related to stress.
Other causes for UGIB, besides ulcer diseases, include erosive esophagitis (11% of cases) which is acid reflux damaging the esophagus, and duodenitis (10% of cases), an inflammation of the first part of the small intestine. Varices, or enlarged veins in the esophagus, account for 5% to 30% of cases depending on how many people in the studied group have chronic liver disease. Mallory-Weiss tear, a tear in the mucous membrane where the esophagus meets the stomach, is responsible for 5% to 15% of UGIB cases, and vascular malformations, which are issues in the formation of blood vessels, account for 5% of cases.
Risk Factors and Frequency for Upper Gastrointestinal Bleeding (GI bleed)
Upper gastrointestinal bleeding (UGIB) is responsible for the majority of acute stomach bleeding cases, making up 75% of them. Each year, between 80 to 150 out of every 100,000 people experience this condition. People who consistently take low doses of aspirin are at a higher risk for noticeable UGIB compared to those who don’t take aspirin. The risk rises even more when aspirin is taken with certain blood-thinning medications, like clopidogrel, with cases of UGIB potentially doubling or tripling. For those on a combined treatment of aspirin, a blood-thinning medication, and a Vitamin K antagonist, the risk of experiencing UGIB significantly shoots up.
- UGIB makes up 75% of all acute stomach bleeding cases.
- Every year, 80 to 150 out of 100,000 people will have UGIB.
- People who regularly take low-dose aspirin are more likely to experience noticeable UGIB than those who don’t.
- The usage of aspirin and clopidogrel can potentially double or triple UGIB cases.
- Being on a treatment plan that includes aspirin, a blood-thinning medication, and a Vitamin K antagonist greatly increases the risk of UGIB.
Signs and Symptoms of Upper Gastrointestinal Bleeding (GI bleed)
When talking with a patient about their medical history, it’s essential to understand any other health conditions they might have. You should also review all their current medications, specifically asking about any use of NSAIDs (non-steroidal anti-inflammatory drugs), antiplatelet drugs, aspirin, or blood thinners. It’s also important to ask about their drinking habits.
The symptoms of gastrointestinal bleeding can vary, but there are important signs to look out for:
- Hematemesis – This is when someone vomits blood or blood clots.
- Melena – This entails dark, sticky bowel movements that smell unusual.
- “Coffee-grounds” – This term describes when someone vomits a dark substance that looks like coffee grounds, which is caused by old blood.
- Hematochezia – This is when fresh blood is passed through the rectum. This symptom usually indicates lower gastrointestinal bleeding but can also be a sign of significant upper gastrointestinal bleeding.
Patients might also experience fainting or low blood pressure if the bleeding is severe enough to affect their blood circulation.
Paying close attention to the patient’s vital signs, including changes when they stand up, is critical. A thorough physical exam can show signs of long-term liver diseases like palmar erythema (redness of the palms), spider angiomas (spider-like blood vessels on the skin), breast enlargement in men, yellowing of the skin and eyes, and fluid buildup in the abdomen. These signs could help determine the cause of the bleeding, such as variceal bleeding from swollen veins.
Testing for Upper Gastrointestinal Bleeding (GI bleed)
When analyzing a suspected upper gastrointestinal bleeding (UGIB), a complete blood count is important. This test will check levels of hemoglobin, hematocrit, and platelets. If the result shows a low MCV, it may suggest that there is ongoing blood loss and potential iron deficiency anemia. Doctors will also evaluate the body’s chemistry, specifically checking for elevated BUN or BUN/Creatinine levels. This, too, can indicate UGIB. In addition, a coagulation panel should also be performed.
There are scoring systems that doctors use to predict which patients might need intervention, and to forecast the probability of rebleeding and death. One such system is the Rockall score. This measures factors such as age, current health conditions, signs of shock, and endoscopic results. The scoring system identifies those at risk of further bleeding and mortality. Individuals with low scores (two or less) are viewed as low risk and have a very small chance of rebleeding and death. Conversely, patients with a score of six or more have a higher probability for both.
Another tool often used for UGIB cases is the Blatchford Score. This scoring system is designed to determine the need for intervention. Based on things like hemoglobin levels, blood pressure, symptoms, and the presence of liver disease and heart failure, a score of six or more indicates a significant risk (over 50%) of requiring an intervention.
If UGIB is suspected, endoscopy is necessary to identify and potentially treat the source of the bleeding. There is ongoing debate as to when it is best to perform an endoscopy, but current guidelines from the American College of Gastroenterology recommend all UGIB patients undergo the procedure within 24 hours of admission, once other medical issues have been addressed. Additionally, patients with higher-risk features might require an endoscopy within 12 hours for improved clinical outcomes.
Treatment Options for Upper Gastrointestinal Bleeding (GI bleed)
Patients need to have at least two large tubes (known as 18-gauge peripheral access catheters) inserted into their veins. Intravenous fluids, which are administered through these tubes, are crucial for maintaining stable blood pressure. If a patient is having difficulty protecting their airways or if they’re vomiting a lot of blood, a medical professional may decide to insert a tube down their throat to help them breathe, a procedure known as elective endotracheal intubation.
Blood transfusions may be administered to certain patients to ensure they have enough red blood cells, targeting a hematocrit (the proportion of red blood cells in the blood) above 20%. For high-risk patients, like older individuals or those with heart diseases, the target is a hematocrit above 30%. However, aiming for a hematocrit beyond these targets isn’t recommended because it could be harmful.
Patients with nonvariceal upper gastrointestinal bleeding (UGIB) are often treated with Proton Pump Inhibitors (PPIs) which reduce stomach acid production. Antacids have been found to change the course of UGIB. If a patient’s bleeding is severe, they may receive an initial large dose of PPI (80-mg bolus), followed by a continuous infusion. Infusion is typically continued for 72 hours in patients with high-risk lesions identified during endoscopy. If the endoscopy results are normal or reveal only low-risk lesions, the PPI infusion can be stopped, and the patient can be given a regular dose either through an IV or orally.
Octreotide, a medication, is used when there’s a suspicion of variceal bleeding. It’s typically given as an initial large intravenous dose followed by a continuous infusion. However, its use is generally not recommended in nonvariceal UGIB, but it can be used for extra support in some cases. It’s mostly used where an endoscopy isn’t available or to help stabilize patients before they receive definitive treatment.
Depending on the findings from the endoscopy, the doctor may require an endoscopic intervention. For instance, if an ulcer with a clean base is present, there’s no need for any intervention. But if active bleeding is seen or if there are signs of recent bleeding, therapies such as heat treatment to stop bleeding, injection of adrenaline, or using clips may be used. In cases of severe lesions, a combination of these may be necessary.
What else can Upper Gastrointestinal Bleeding (GI bleed) be?
- An enlargement in the aorta, the main blood vessel in the body (known as an abdominal aortic aneurysm)
- Sudden inflammation or swelling in the stomach (known as acute gastritis)
- An abnormal change in the cells in the lower part of the esophagus, a condition known as Barret’s esophagus
- Cancer of the esophagus (the tube that carries food from your mouth to your stomach)
- Inflammation in the esophagus, commonly known as esophagitis
- Stomach cancer, also referred to as gastric cancer
- A blockage of the passageway leading out of the stomach, which is referred to as a gastric outlet obstruction
- Sores that develop on the lining of the stomach, called gastric ulcers
- A rare tumor that forms in certain cells of the stomach, called a gastrinoma
