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Upper Gastrointestinal Bleeding Clinical Presentation

  • Author: Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF; Chief Editor: BS Anand, MD  more...
 
Updated: Mar 21, 2016
 

History

The history and physical examination of the patient provide crucial information for the initial evaluation of persons presenting with a GI tract hemorrhage.[5, 10] Important information to obtain includes potential comorbid conditions, medication history, and potential toxic exposures, as well as the severity, timing, duration, and volume of the bleeding.[5]

History findings include weakness, dizziness, syncope associated with hematemesis (coffee ground vomitus), and melena (black stools with a rotten odor).

Occasionally, a brisk UGIB manifests as hematochezia (red or maroon stools); the redder the stool, the more rapid the transit, which suggests a large upper tract hemorrhage. Laine and Shah found that 15% of patients presenting with hematochezia had an upper gastrointestinal source of bleeding identified at urgent esophagogastroduodenoscopy.[27]

Patients may have a history of dyspepsia (especially nocturnal symptoms), ulcer disease, early satiety, and NSAID or aspirin use. A history of recent aspirin ingestion suggests that the patient may have NSAID gastropathy with an enhanced bleeding diathesis from poor platelet adhesiveness.[10]

Many patients with UGIB who are taking NSAIDs present without dyspepsia but with hematemesis or melena as their first symptom, owing to the analgesic effect of the NSAID. Low-dose aspirin (81 mg) has also been associated with UGIB with or without the addition of NSAID therapy. Using the lowest effective dose for both short-term and long-term users is recommended.[28]

Patients with a history of ulcers are at an especially increased risk for UGIB when placed on aspirin or NSAID therapy and should receive continuous acid suppression with a proton pump inhibitor (PPI). The patient’s ulcer history is also important because recurrence of ulcer disease is common, especially if he or she has not been treated for H pylori gastritis or the antibiotic therapy has failed.

Patients may present in a more subacute phase, with a history of dyspepsia and occult intestinal bleeding manifesting as a positive fecal occult blood test result or as iron deficiency anemia.

A history of chronic alcohol use of more than 50 g/d or chronic viral hepatitis (B or C) increases the risk of variceal hemorrhage, gastric antral vascular ectasia (GAVE), or portal gastropathy.

The finding of subcutaneous emphysema with a history of vomiting is suggestive of Boerhaave syndrome (esophageal perforation) and requires prompt consideration of surgical therapy.

The presence of postural hypotension indicates more rapid and severe blood loss.

A meta-analysis documented the incidence of acute UGIB symptoms as follows (see also Physical Examination, below)[1] :

  • Hematemesis - 40-50%
  • Melena - 70-80%
  • Hematochezia - 15-20%
  • Either hematochezia or melena - 90-98%
  • Syncope - 14.4%
  • Presyncope - 43.2%
  • Symptoms 30 days prior to admission - No percentage available
  • Dyspepsia - 18%
  • Epigastric pain - 41%
  • Heartburn - 21%
  • Diffuse abdominal pain - 10%
  • Dysphagia - 5%
  • Weight loss - 12%
  • Jaundice - 5.2%

The importance of the above clinical signs/symptoms in determining the source of GI bleeding is demonstrated in the table below.[1]

Table 1. Probable Source of GI Bleeding Within the Gut (Open Table in a new window)

Clinical Indicator Probability of Upper GI Source Probability of Lower GI Source
Hematemesis Almost certain Rare
Melena Probable Possible
Hematochezia Possible Probable
Blood-streaked stool Rare Almost certain
Occult blood in stool Possible Possible
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Physical Examination

The goal of the patient's physical examination is to evaluate for shock and blood loss.

Patients present with an ulcer that has bled or is actively bleeding (although approximately 80% of ulcers stop bleeding).

Hematemesis and melena are the most common presentations of acute UGIB, and patients may present with both symptoms.

Assessing the patient for hemodynamic instability and clinical signs of poor perfusion is important early in the initial evaluation to properly triage patients with massive hemorrhage to ICU settings.

Worrisome clinical signs and symptoms of hemodynamic compromise include tachycardia of more than 100 beats per minute (bpm), systolic blood pressure of less than 90 mm Hg, cool extremities, syncope, and other obvious signs of shock, ongoing brisk hematemesis, or the occurrence of maroon or bright-red stools, which requires rapid blood transfusion.[29]

Pulse and blood pressure should be checked with the patient in supine and upright positions to note the effect of blood loss. Significant changes in vital signs with postural changes indicate an acute blood loss of approximately 20% or more of the blood volume.

Signs of chronic liver disease should be noted, including spider angiomata, gynecomastia, increased luneals, splenomegaly, ascites, pedal edema, and asterixis.

Signs of tumor are uncommon but portend a poor prognosis. Signs include a nodular liver, an abdominal mass, and enlarged and firm lymph nodes. The finding of telangiectasias may indicate the rare case of Osler-Weber-Rendu syndrome.

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Contributor Information and Disclosures
Author

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF Associate Professor of Clinical Medicine, Albert Einstein College of Medicine of Yeshiva University; Associate Professor of Clinical Medicine, Hofstra Medical School

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, New York Society for Gastrointestinal Endoscopy, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Shahzad Iqbal, MD Advanced Endoscopy Fellow, Department of Gastroenterology, Columbia University Medical Center

Shahzad Iqbal, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

James de Caestecker, DO Instructor, Department of Surgery, MCP Hahnemann University

James de Caestecker, DO is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association

Disclosure: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

Alex Jacocks, MD Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine

Disclosure: Nothing to disclose.

Jason Straus, MD Staff Physician, Department of Surgery, Wright State University School of Medicine

Jason Straus, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. al-Assi MT, Genta RM, Karttunen TJ, Graham DY. Ulcer site and complications: relation to Helicobacter pylori infection and NSAID use. Endoscopy. 1996 Feb. 28(2):229-33. [Medline].

  2. Frattaroli FM, Casciani E, Spoletini D, Polettini E, Nunziale A, Bertini L, et al. Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding. World J Surg. 2009 Oct. 33(10):2209-17. [Medline].

  3. Lam KL, Wong JC, Lau JY. Pharmacological treatment in upper gastrointestinal bleeding. Curr Treat Options Gastroenterol. 2015 Dec. 13 (4):369-76. [Medline].

  4. Curdia Goncalves T, Rosa B, Cotter J. New insights on an old medical emergency: non-portal hypertension related upper gastrointestinal bleeding. Rev Esp Enferm Dig. 2016 Mar 4. 108:[Medline].

  5. Lirio RA. Management of upper gastrointestinal bleeding in children: variceal and nonvariceal. Gastrointest Endosc Clin N Am. 2016 Jan. 26 (1):63-73. [Medline].

  6. Fallah MA, Prakash C, Edmundowicz S. Acute gastrointestinal bleeding. Med Clin North Am. 2000 Sep. 84(5):1183-208. [Medline].

  7. Pongprasobchai S, Nimitvilai S, Chasawat J, Manatsathit S. Upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding. World J Gastroenterol. 2009 Mar 7. 15(9):1099-104. [Medline]. [Full Text].

  8. Straube S, Tramèr MR, Moore RA, Derry S, McQuay HJ. Mortality with upper gastrointestinal bleeding and perforation: effects of time and NSAID use. BMC Gastroenterol. 2009 Jun 5. 9:41. [Medline]. [Full Text].

  9. Yavorski RT, Wong RK, Maydonovitch C, Battin LS, Furnia A, Amundson DE. Analysis of 3,294 cases of upper gastrointestinal bleeding in military medical facilities. Am J Gastroenterol. 1995 Apr. 90(4):568-73. [Medline].

  10. Stabile BE, Stamos MJ. Surgical management of gastrointestinal bleeding. Gastroenterol Clin North Am. 2000 Mar. 29(1):189-222. [Medline].

  11. Cheung FK, Lau JY. Management of massive peptic ulcer bleeding. Gastroenterol Clin North Am. 2009 Jun. 38(2):231-43. [Medline].

  12. Tiriveedhi K, Simon J, Cerulli MA. Does Gastric Lavage Reduce the Detection of Helicobacter Pylori in the Biopsy Specimens?. Gastrointest Endosc. 2007. 67:Abstract 239.

  13. Boonpongmanee S, Fleischer DE, Pezzullo JC, Collier K, Mayoral W, Al-Kawas F, et al. The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated. Gastrointest Endosc. 2004 Jun. 59(7):788-94. [Medline].

  14. Elmunzer BJ, Young SD, Inadomi JM, Schoenfeld P, Laine L. Systematic review of the predictors of recurrent hemorrhage after endoscopic hemostatic therapy for bleeding peptic ulcers. Am J Gastroenterol. 2008 Oct. 103(10):2625-32; quiz 2633. [Medline].

  15. Sung JJ, Tsoi KK, Ma TK, Yung MY, Lau JY, Chiu PW. Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases. Am J Gastroenterol. 2010 Jan. 105(1):84-9. [Medline].

  16. Corson JD, Williamson RCN, eds. Surgery. London, UK: Mosby-Year Book; 2001.

  17. Stollman N, Metz DC. Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. J Crit Care. 2005 Mar. 20(1):35-45. [Medline].

  18. Cameron JL, ed. Current Surgical Therapy. 5th ed. St. Louis, Mo: Mosby-Year Book; 1995.

  19. Jensen DM, Machicado GA, Hirabayashi K. Randomized controlled study of 3 different types of hemoclips for hemostasis of bleeding canine acute gastric ulcers. Gastrointest Endosc. 2006 Nov. 64(5):768-73. [Medline].

  20. Larson G, Schmidt T, Gott J, Bond S, O'Connor CA, Richardson JD. Upper gastrointestinal bleeding: predictors of outcome. Surgery. 1986 Oct. 100(4):765-73. [Medline].

  21. Reilly HF 3rd, al-Kawas FH. Dieulafoy's lesion. Diagnosis and management. Dig Dis Sci. 1991 Dec. 36(12):1702-7. [Medline].

  22. Pilotto A, Maggi S, Noale M, Franceschi M, Parisi G, Crepaldi G. Development and validation of a new questionnaire for the evaluation of upper gastrointestinal symptoms in the elderly population: a multicenter study. J Gerontol A Biol Sci Med Sci. 2010 Feb. 65(2):174-8. [Medline].

  23. Jairath V, Desborough MJ. Modern-day management of upper gastrointestinal haemorrhage. Transfus Med. 2015 Dec 28. [Medline].

  24. Lanas A, Perez-Aisa MA, Feu F, Ponce J, Saperas E, Santolaria S, et al. A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal antiinflammatory drug use. Am J Gastroenterol. 2005 Aug. 100(8):1685-93. [Medline].

  25. Peter DJ, Dougherty JM. Evaluation of the patient with gastrointestinal bleeding: an evidence based approach. Emerg Med Clin North Am. 1999 Feb. 17(1):239-61, x. [Medline].

  26. Adler DG, Leighton JA, Davila RE, Hirota WK, Jacobson BC, Qureshi WA, et al. ASGE guideline: The role of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointest Endosc. 2004 Oct. 60(4):497-504. [Medline].

  27. Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol. 2010 Dec. 105(12):2636-41; quiz 2642. [Medline].

  28. Huang ES, Strate LL, Ho WW, Lee SS, Chan AT. Long-term use of aspirin and the risk of gastrointestinal bleeding. Am J Med. 2011 May. 124(5):426-33. [Medline]. [Full Text].

  29. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Course Manual. Chicago, Ill: American College of Surgeons; 1997.

  30. Bornman PC, Theodorou NA, Shuttleworth RD, Essel HP, Marks IN. Importance of hypovolaemic shock and endoscopic signs in predicting recurrent haemorrhage from peptic ulceration: a prospective evaluation. Br Med J (Clin Res Ed). 1985 Jul 27. 291(6490):245-7. [Medline]. [Full Text].

  31. Silverstein FE, Gilbert DA, Tedesco FJ, Buenger NK, Persing J. The national ASGE survey on upper gastrointestinal bleeding. II. Clinical prognostic factors. Gastrointest Endosc. 1981 May. 27(2):80-93. [Medline].

  32. Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3. 368(1):11-21. [Medline].

  33. Waknine Y. GI Bleeds: Withholding Transfusions Boosts Survival. Medscape Medical News. January 15, 2013. [Full Text].

  34. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. N Engl J Med. 2013 May 16. [Medline].

  35. [Guideline] Scottish Intercollegiate Guidelines Network (SIGN). Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2008 Sep. (SIGN publication; no. 105): [Full Text].

  36. Peloquin JM, Seraj SM, King LY, Campbell EJ, Ananthakrishnan AN, Richter JM. Diagnostic and therapeutic yield of endoscopy in patients with elevated INR and gastrointestinal bleeding. Am J Med. 2015 Dec 20. [Medline].

  37. [Guideline] Schenker MP, Majdalany BS, Funaki BS, et al; and Expert Panel on Vascular Imaging and Interventional Radiology. ACR Appropriateness Criteria® upper gastrointestinal bleeding. [online publication]. Reston (VA): American College of Radiology (ACR); 2010. [Full Text].

  38. Chandran S, Testro A, Urquhart P, La Nauze R, Ong S, Shelton E, et al. Risk stratification of upper GI bleeding with an esophageal capsule. Gastrointest Endosc. 2013 Feb 26. [Medline].

  39. Iwasaki H, Shimura T, Yamada T, Aoki M, Nomura S, Kusakabe A, et al. Novel Nasogastric Tube-Related Criteria for Urgent Endoscopy in Nonvariceal Upper Gastrointestinal Bleeding. Dig Dis Sci. 2013 May 22. [Medline].

  40. Monteiro S, Goncalves TC, Magalhaes J, Cotter J. Upper gastrointestinal bleeding risk scores: Who, when and why?. World J Gastrointest Pathophysiol. 2016 Feb 15. 7 (1):86-96. [Medline].

  41. 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. Am J Gastroenterol. 2004 Apr. 99(4):619-22. [Medline].

  42. Kaplan LJ, McPartland K, Santora TA, Trooskin SZ. Start with a subjective assessment of skin temperature to identify hypoperfusion in intensive care unit patients. J Trauma. 2001 Apr. 50(4):620-7; discussion 627-8. [Medline].

  43. Sarin N, Monga N, Adams PC. Time to endoscopy and outcomes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009 Jul. 23(7):489-93. [Medline]. [Full Text].

  44. Green FW Jr, Kaplan MM, Curtis LE, Levine PH. Effect of acid and pepsin on blood coagulation and platelet aggregation. A possible contributor prolonged gastroduodenal mucosal hemorrhage. Gastroenterology. 1978 Jan. 74(1):38-43. [Medline].

  45. Lau JY, Leung WK, Wu JC, et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med. 2007 Apr 19. 356(16):1631-40. [Medline].

  46. Barkun AN, Herba K, Adam V, Kennedy W, Fallone CA, Bardou M. High-dose intravenous proton pump inhibition following endoscopic therapy in the acute management of patients with bleeding peptic ulcers in the USA and Canada: a cost-effectiveness analysis. Aliment Pharmacol Ther. 2004 Mar 1. 19(5):591-600. [Medline].

  47. Laine L, Shah A, Bemanian S. Intragastric pH with oral vs intravenous bolus plus infusion proton-pump inhibitor therapy in patients with bleeding ulcers. Gastroenterology. 2008 Jun. 134(7):1836-41. [Medline].

  48. Leontiadis GI, Sharma VK, Howden CW. Proton pump inhibitor therapy for peptic ulcer bleeding: Cochrane collaboration meta-analysis of randomized controlled trials. Mayo Clin Proc. 2007 Mar. 82(3):286-96. [Medline].

  49. Lau JY, Sung JJ, Lam YH, et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med. 1999 Mar 11. 340(10):751-6. [Medline].

  50. Leontiadis GI, Sharma VK, Howden CW. Systematic review and meta-analysis of proton pump inhibitor therapy in peptic ulcer bleeding. BMJ. 2005 Mar 12. 330(7491):568. [Medline]. [Full Text].

  51. Cooper GS, Chak A, Way LE, Hammar PJ, Harper DL, Rosenthal GE. Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointest Endosc. 1999 Feb. 49(2):145-52. [Medline].

  52. [Guideline] Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010 Jan 19. 152(2):101-13. [Medline]. [Full Text].

  53. Matsui S, Kamisako T, Kudo M, Inoue R. Endoscopic band ligation for control of nonvariceal upper GI hemorrhage: comparison with bipolar electrocoagulation. Gastrointest Endosc. 2002 Feb. 55(2):214-8. [Medline].

  54. Giday SA, Kim Y, Krishnamurty DM, et al. Long-term randomized controlled trial of a novel nanopowder hemostatic agent (TC-325) for control of severe arterial upper gastrointestinal bleeding in a porcine model. Endoscopy. 2011 Apr. 43(4):296-9. [Medline].

  55. Vargas HE, Gerber D, Abu-Elmagd K. Management of portal hypertension-related bleeding. Surg Clin North Am. 1999 Feb. 79(1):1-22. [Medline].

  56. Cipolletta L, Bianco MA, Marmo R, Rotondano G, Piscopo R, Vingiani AM, et al. Endoclips versus heater probe in preventing early recurrent bleeding from peptic ulcer: a prospective and randomized trial. Gastrointest Endosc. 2001 Feb. 53(2):147-51. [Medline].

  57. Lin HJ, Hsieh YH, Tseng GY, Perng CL, Chang FY, Lee SD. A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding. Am J Gastroenterol. 2002 Sep. 97(9):2250-4. [Medline].

  58. Saltzman JR, Strate LL, Di Sena V, Huang C, Merrifield B, Ookubo R, et al. Prospective trial of endoscopic clips versus combination therapy in upper GI bleeding (PROTECCT--UGI bleeding). Am J Gastroenterol. 2005 Jul. 100(7):1503-8. [Medline].

  59. Bini EJ, Cohen J. Endoscopic treatment compared with medical therapy for the prevention of recurrent ulcer hemorrhage in patients with adherent clots. Gastrointest Endosc. 2003 Nov. 58(5):707-14. [Medline].

  60. Freeman ML, Cass OW, Peine CJ, Onstad GR. The non-bleeding visible vessel versus the sentinel clot: natural history and risk of rebleeding. Gastrointest Endosc. 1993 May-Jun. 39(3):359-66. [Medline].

  61. Poxon VA, Keighley MR, Dykes PW, Heppinstall K, Jaderberg M. Comparison of minimal and conventional surgery in patients with bleeding peptic ulcer: a multicentre trial. Br J Surg. 1991 Nov. 78(11):1344-5. [Medline].

  62. Lau JY, Sung JJ, Lam YH, Chan AC, Ng EK, Lee DW, et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med. 1999 Mar 11. 340(10):751-6. [Medline].

  63. Leontiadis GI, Howden CW. The role of proton pump inhibitors in the management of upper gastrointestinal bleeding. Gastroenterol Clin North Am. 2009 Jun. 38(2):199-213. [Medline].

  64. Targownik LE, Bolton JM, Metge CJ, Leung S, Sareen J. Selective serotonin reuptake inhibitors are associated with a modest increase in the risk of upper gastrointestinal bleeding. Am J Gastroenterol. 2009 Jun. 104(6):1475-82. [Medline].

  65. So JB, Yam A, Cheah WK, Kum CK, Goh PM. Risk factors related to operative mortality and morbidity in patients undergoing emergency gastrectomy. Br J Surg. 2000 Dec. 87(12):1702-7. [Medline].

  66. Sadic J, Borgström A, Manjer J, Toth E, Lindell G. Bleeding peptic ulcer - time trends in incidence, treatment and mortality in Sweden. Aliment Pharmacol Ther. 2009 Aug 15. 30(4):392-8. [Medline].

  67. Jo Y, Matsumoto T, Aoyagi K, Yano Y, Kawasaki A, Fujishima M. Endoscopic band ligation device for bleeding gastric angiodysplasia. Gastrointest Endosc. 1999 Oct. 50(4):599. [Medline].

  68. Socrate AM, Rosati L, Locati P. Surgical treatment of aorto-enteric fistulas. Minerva Cardioangiol. 2001 Feb. 49(1):37-45. [Medline].

  69. Young RM, Cherry KJ Jr, Davis PM, Gloviczki P, Bower TC, Panneton JM, et al. The results of in situ prosthetic replacement for infected aortic grafts. Am J Surg. 1999 Aug. 178(2):136-40. [Medline].

  70. Deshpande A, Lovelock M, Mossop P, Denton M, Vidovich J, Gurry J. Endovascular repair of an aortoenteric fistula in a high-risk patient. J Endovasc Surg. 1999 Nov. 6(4):379-84. [Medline].

  71. Lonn L, Dias N, Veith Schroeder T, Resch T. Is EVAR the treatment of choice for aortoenteric fistula?. J Cardiovasc Surg (Torino). 2010 Jun. 51(3):319-27. [Medline].

  72. Burks JA Jr, Faries PL, Gravereaux EC, Hollier LH, Marin ML. Endovascular repair of bleeding aortoenteric fistulas: a 5-year experience. J Vasc Surg. 2001 Dec. 34(6):1055-9. [Medline].

  73. Abou-Zamzam AM Jr, Bianchi C, Mazraany W, Teruya TH, Hopewell J, Vannix RS, et al. Aortoenteric fistula development following endovascular abdominal aortic aneurysm repair: a case report. Ann Vasc Surg. 2003 Mar. 17(2):119-22. [Medline].

  74. Tseng PH, Liou JM, Lee YC, Lin LY, Yan-Zhen Liu A, Chang DC, et al. Emergency endoscopy for upper gastrointestinal bleeding in patients with coronary artery disease. Am J Emerg Med. 2009 Sep. 27(7):802-9. [Medline].

  75. Penston JG, Wormsley KG. Review article: maintenance treatment with H2-receptor antagonists for peptic ulcer disease. Aliment Pharmacol Ther. 1992 Feb. 6(1):3-29. [Medline].

  76. Lai KC, Lam SK, Chu KM, Wong BC, Hui WM, Hu WH, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med. 2002 Jun 27. 346(26):2033-8. [Medline].

  77. Raskin JB, White RH, Jackson JE, Weaver AL, Tindall EA, Lies RB, et al. Misoprostol dosage in the prevention of nonsteroidal anti-inflammatory drug-induced gastric and duodenal ulcers: a comparison of three regimens. Ann Intern Med. 1995 Sep 1. 123(5):344-50. [Medline].

  78. Podolsky I, Storms PR, Richardson CT, Peterson WL, Fordtran JS. Gastric adenocarcinoma masquerading endoscopically as benign gastric ulcer. A five-year experience. Dig Dis Sci. 1988 Sep. 33(9):1057-63. [Medline].

  79. Levine JE, Leontiadis GI, Sharma VK, Howden CW. Meta-analysis: the efficacy of intravenous H2-receptor antagonists in bleeding peptic ulcer. Aliment Pharmacol Ther. 2002 Jun. 16(6):1137-42. [Medline].

  80. Bai Y, Guo JF, Li ZS. Meta-analysis: erythromycin before endoscopy for acute upper gastrointestinal bleeding. Aliment Pharmacol Ther. 2011 Jul. 34(2):166-71. [Medline].

  81. Barkun AN, Bardou M, Martel M, Gralnek IM, Sung JJ. Prokinetics in acute upper GI bleeding: a meta-analysis. Gastrointest Endosc. 2010 Dec. 72(6):1138-45. [Medline].

  82. Brooks M. Poorer peptic ulcer outcomes without H. pylori etiology. Reuters Health Information. July 9, 2013. [Full Text].

  83. Brooks M. SSRIs Linked to Upper GI Bleeds. Medscape Medical News. Available at http://www.medscape.com/viewarticle/811547. Accessed: September 30, 2012.

  84. Chason RD, Reisch JS, Rockey DC. More favorable outcomes with peptic ulcer bleeding due to Helicobacter pylori. Am J Med. 2013 Jul 3. [Medline].

  85. Wang YP, Chen YT, Tsai CF, et al. Short-term use of serotonin reuptake inhibitors and risk of upper gastrointestinal bleeding. Am J Psychiatry. 2014 Jan. 171 (1):54-61. [Medline].

  86. Fujishiro M, Iguchi M, Kakushima N, et al. Guidelines for endoscopic managements of non-variceal upper gastrointestinal bleeding. Dig Endosc. 2016 Feb 22. [Medline].

 
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Ulcer with active bleeding.
Ulcer with a clean base.
Diagram of an ulcer with a clean base.
Ulcer with an overlying clot.
Ulcer with a visible vessel.
Diagram of an ulcer with a visible vessel.
Table 1. Probable Source of GI Bleeding Within the Gut
Clinical Indicator Probability of Upper GI Source Probability of Lower GI Source
Hematemesis Almost certain Rare
Melena Probable Possible
Hematochezia Possible Probable
Blood-streaked stool Rare Almost certain
Occult blood in stool Possible Possible
Table 2. Estimated Fluid and Blood Losses in Shock
  Class 1 Class 2 Class 3 Class 4
Blood Loss, mL Up to 750 750-1500 1500-2000 >2000
Blood Loss,% blood volume Up to 15% 15-30% 30-40% >40%
Pulse Rate, bpm < 100 >100 >120 >140
Blood Pressure Normal Normal Decreased Decreased
Respiratory Rate Normal or Increased Decreased Decreased Decreased
Urine Output, mL/h >35 30-40 20-30 14-20
CNS/Mental Status Slightly



anxious



Mildly



anxious



Anxious,



confused



Confused,



lethargic



Fluid Replacement, 3-for-1 rule Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood
Table 3. Effect of Number of Packed Erythrocyte Transfusions on Need for Surgery and Mortality from UGIB
Number of Units Transfused Need for Surgery, % Mortality Rate, %
0 4 4
1-3 6 14
4-5 17 28
>5 57 43
Table 4. Effect of the Color of the Nasogastric Aspirate and of the Stool on UGIB Mortality Rate
Nasogastric Aspirate Color Stool Color Mortality Rate, %
Clear Brown or red 6
Coffee-ground Brown or black 8.2
  Red 19.1
Red blood Black 12.3
  Brown 19.4
  Red 28.7
Table 5. Ulcer Characteristics and Correlations
Ulcer Characteristics Prevalence Rate, % Rebleeding Rate, % Surgery Rate, % Mortality Rate, %
Clean base 42 5 0.5 2
Flat spot 20 10 6 3
Adherent clot 17 22 10 7
Visible vessel 17 43 34 11
Active bleeding 18 55 35 11
Table 6. Recurrent Ulcer and Postgastrectomy Syndromes After Operations for Duodenal Ulcer
Original Operation Recurrence Rate, % Postgastrectomy Syndrome Rate, % Mortality Rate, %
Proximal gastric vagotomy 10 5 0.1
Truncal vagotomy and drainage 7 20-30 < 1
Truncal vagotomy and antrectomy



Billroth I or Billroth II



1 30-50 0-5
Truncal vagotomy and antrectomy



Roux-en-Y



5-10 50-60 0-5
Table 7. Effects of Operations for PUD on Gastric Emptying and Motility
Operation Antral Innervation Liquid Emptying Solid Emptying
Proximal gastric vagotomy Preserved Fast Normal
Truncal vagotomy Divided Fast Slow
Truncal vagotomy and drainage Divided Fast Fast
Truncal vagotomy and antrectomy Divided Fast Fast
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