Upper Gastrointestinal Bleeding Workup

  • Author: Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Nov 23, 2011
 

Approach Considerations

An electrocardiogram (ECG) should be ordered to exclude arrhythmia and cardiac disease, especially acute myocardial infarction due to hypotension.

Esophagogastroduodenoscopy may increase the risk of arrhythmias.

Performing a troponin test may be useful in identifying patients with severe coronary ischemia or atypical myocardial infarction.

Go to Imaging of Upper Gastrointestinal Bleeding and Imaging of Esophageal Varices for complete information on these topics.

Assessment of hemorrhagic shock

As previously mentioned, patients who present in hemorrhagic shock have a mortality rate of up to 30%. Hemorrhage may be classified based on the amount of blood loss, as noted in the following table.[25]

Table 2. Estimated Fluid and Blood Losses in Shock (Open Table in a new window)

Class 1Class 2Class 3Class 4
Blood Loss, mLUp to 750750-15001500-2000>2000
Blood Loss,% blood volumeUp to 15%15-30%30-40%>40%
Pulse Rate, bpm< 100>100>120>140
Blood PressureNormalNormalDecreasedDecreased
Respiratory RateNormal or IncreasedDecreasedDecreasedDecreased
Urine Output, mL/h>3530-4020-3014-20
CNS/Mental StatusSlightly



anxious



Mildly



anxious



Anxious,



confused



Confused,



lethargic



Fluid Replacement, 3-for-1 ruleCrystalloidCrystalloidCrystalloid and bloodCrystalloid and blood

This classification scheme aids in understanding the clinical manifestations of hemorrhagic shock. In early class 1 shock, the patient may have normal vital signs, even with a 15% loss of total blood volume. As the percentage of blood volume loss increases, pertinent clinical signs, symptoms, and findings become more apparent.

Although early cardiovascular changes occur as blood loss continues, urine output, as a sign of end organ renal perfusion, is only mildly affected until class 3 hemorrhage has occurred.

Bornman et al correlated the presence of shock (defined as a pulse rate >100 bpm or SBP < 100 mm Hg) with the incidence of rebleeding rates after initial nonsurgical intervention.[25] They found that rebleeding (a marker for increased mortality and need for surgery) occurred in 2% of patients without shock, in 18% with isolated tachycardia, and in 48% with shock.

Schiller et al determined that SBP is a sensitive clinical marker for helping to predict mortality. They correlated mortality rates based on the patient's SBP at the time of bleeding and found mortality rates of 8% for patients with SBP more than 100 mm Hg, rates of 17% for SBP of 80-90 mm Hg, and rates of more than 30% for SBP less than 80 mm Hg.

Unless the patient has evidence of shock, orthostatic testing should be performed to assess and document a hypovolemic state. A positive tilt test finding is defined as an SBP decrease of 10 mm Hg and a pulse rate increase of 20 bpm with standing compared to the supine position. The ASGE survey was able to correlate orthostatic changes with the incidence of mortality.[26] The mortality rate when orthostatic changes are present is 13.6%, compared to 8.7% when they are absent.

Knopp et al studied the use of the tilt test in phlebotomized healthy volunteers and found that a positive tilt test result consistently correlated with a blood loss of 1000 mL. This becomes extremely useful when evaluating patients with class 1 hemorrhagic shock.

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CBC With Platelet Count and Differential

A complete blood count (CBC) is necessary to assess the level of blood loss in a patient with upper gastrointestinal bleeding. Where possible, having the patient's previous results is useful to gauge this loss. CBC should be checked frequently (q4-6h) during the first day.

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Hemoglobin Value and Type and Crossmatch Blood

Based on the patient's initial hemoglobin level and clinical assessment of shock, a type and screen or type and crossmatch should be ordered. The patient should be crossmatched for 2-6 units, based on the rate of active bleeding. The hemoglobin level should be monitored serially in order to follow the trend. An unstable hemoglobin level may signify ongoing hemorrhage requiring further intervention.

Patients generally require blood transfusions because of hypoperfusion and hypovolemia. Patients with significant comorbid conditions (eg, advanced cardiovascular disease) should receive blood transfusions to maintain myocardial oxygen delivery to avoid myocardial ischemia.

According to the 2008 SIGN guideline, patients in shock should receive prompt volume replacement.[27]

One of the criteria used to determine the need for surgical intervention is the number of units of transfused blood required to resuscitate the patient. The more units required, the higher the mortality rate.[15] Operative intervention is indicated once the blood transfusion number reaches more than 5 units, as noted in the following table.[15]

Table 3. Effect of Number of Packed Erythrocyte Transfusions on Need for Surgery and Mortality from UGIB (Open Table in a new window)

Number of Units TransfusedNeed for Surgery, %Mortality Rate, %
044
1-3614
4-51728
>55743
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BMP, BUN, and Coagulation

The basic metabolic profile (BMP) is useful in evaluating for renal comorbidity; however, blood in the upper intestine can elevate the BUN (blood urea nitrogen) level as well. Measurement of coagulation parameters is necessary to assess for continued bleeding. Abnormalities should be corrected rapidly.

The BUN-to-creatinine ratio increases with upper gastrointestinal bleeding (UGIB). A ratio of greater than 36 in a patient without renal insufficiency is suggestive of UGIB.

Coagulation Profile

The patient's prothrombin time (PT), activated partial thromboplastin time, and International Normalized Ratio (INR) should be checked to document the presence of a coagulopathy. The coagulopathy may be consumptive and associated with a thrombocytopenia.

A platelet count of less than 50 with active acute hemorrhage requires a platelet transfusion and fresh frozen plasma in an attempt to replete lost clotting factors.

The coagulopathy could be a marker for advanced liver disease.

The PT is used in calculating the Child-Pugh score.[11] Elevated aminotransferase levels are a result of hepatocellular injury. Increased levels of alkaline phosphatase and gamma–glutamyl transpeptidase are indicative of cholestatic liver disease.

Prolongation of the PT based on an INR of more than 1.5 may indicate moderate liver impairment.

A fibrinogen level of less than 100 mg/dL also indicates advanced liver disease with extremely poor synthetic function.

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Calcium Level

Assessing patients’ calcium levels is useful in identifying individuals with hyperparathyroidism as well as in monitoring calcium in patients receiving multiple transfusions of citrated blood. Hypercalcemia increases acid secretion.

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Gastrin level

A gastrin level can identify the rare patient with gastrinoma as the cause of upper gastrointestinal bleeding and multiple ulcers.

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Endoscopy

The development of endoscopy has provided clinicians with the ability for diagnostic and therapeutic approaches to bleeding from the GI tract. Endoscopic examination of the upper GI tract provides useful information regarding the source and site of bleeding.[26]

Endoscopic findings and their incidence rate in patients with UGIB include the following:

  • Duodenal ulcer - 24.3%
  • Gastric erosion - 23.4%
  • Gastric ulcer - 21.3%
  • Esophageal varices - 10.3%
  • Mallory-Weiss tear - 7.2%
  • Esophagitis - 6.3%
  • Duodenitis - 5.8%
  • Neoplasm - 2.9%
  • Stomal (marginal) ulcer - 1.8%
  • Esophageal ulcer - 1.7%
  • Other/miscellaneous - 6.8%

Endoscopy should be performed immediately after endotracheal intubation (if indicated), hemodynamic stabilization, and adequate monitoring in an ICU setting have been achieved. The 2010 American College of Radiology (ACR) appropriateness criteria for upper gastrointestinal bleeding recommend upper endoscopy as the initial diagnostic examination for all patients presumed to have UGIB.[28]

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Chest Radiography

Chest radiographs should be ordered to exclude aspiration pneumonia, effusion, and esophageal perforation; abdominal scout and upright films should be ordered to exclude perforated viscus and ileus.

Go to Imaging of Upper Gastrointestinal Bleeding and Imaging of Esophageal Varices for complete information on these topics.

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Barium Contrast Studies

Barium contrast studies are not usually helpful and can make endoscopic procedures more difficult (ie, white barium obscuring the view) and dangerous (ie, risk of aspiration).

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CT Scanning

Computed tomography (CT) scanning and ultrasonography may be indicated for the evaluation of liver disease with cirrhosis, cholecystitis with hemorrhage, pancreatitis with pseudocyst and hemorrhage, aortoenteric fistula, and other unusual causes of upper GI hemorrhage.[29] The 2010 ACR criteria state that CT is particularly useful for localizing obscure UGIB and for evaluating a patient with UGIB and a history of aortic reconstruction or pancreaticobiliary procedure.[28]

CT scanning is useful in the diagnosis of aortoenteric fistula because images may reveal thickened bowel, perigraft fluid collection, extraluminal gas, or inflammatory changes in the area of the duodenum and aortic graft.

Go to Imaging of Upper Gastrointestinal Bleeding and Imaging of Esophageal Varices for complete information on these topics.

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Nuclear Medicine Scanning

Nuclear medicine scans may be useful in determining the area of active hemorrhage. However, the 2010 ACR criteria state that Tc-99m-labeled erythrocyte scans are of limited value in diagnosing UGIB, but continue to be useful in certain cases of obscure UGIB.[28]

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Angiography

Angiography may be useful if bleeding persists and endoscopy fails to identify a bleeding site. According to the 2010 ACR guidelines, angiography along with transcatheter arterial embolization (TAE) should be considered for all patients with a known source of arterial UGIB that does not respond to endoscopic management, with active bleeding and a negative endoscopy.[28]

In cases of aortoenteric fistula, angiography requires active bleeding (1 mL/min) to be diagnostic.

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Nasogastric Lavage

This procedure may confirm recent bleeding (coffee ground appearance), possible active bleeding (red blood in the aspirate that does not clear), or a lack of blood in the stomach (active bleeding less likely but does not exclude an upper GI lesion).

A nasogastric tube is an important diagnostic tool, and tube placement can reduce the patient's need to vomit. Placement for diagnostic purposes is not contraindicated in patients with possible esophageal varices.

The characteristics of the nasogastric lavage fluid (eg, red, coffee grounds, clear) and the stool (eg, red, black, brown) can indicate the severity of the hemorrhage. Red blood with red stool is associated with an increased mortality rate from more active bleeding compared with negative aspirate findings with brown stool.

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Histologic Findings

The bleeding vessel lies in the deepest layer of the ulcer. Fibrinoid necrosis is observed at the site of perforation of the vessel. Pseudoaneurysmal dilation of the vessel may be present at the site of perforation. Biopsy samples should be taken from the edge of a gastric ulcer to rule out carcinoma.

The characteristic lesion of H pylori is chronic active gastritis with the organisms observed after routine staining. The lesion of gastric antral vascular ectasia is capillary dilation with fibrin clots and fibromuscular hyperplasia.

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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, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, and New York 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, and American Society of Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Additional Contributors

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

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Ulcer with active bleeding.
Ulcer with a clean base.
Diagram of an ulcer with a clean base.
Ulcer with a flat spot.
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 IndicatorProbability of Upper GI SourceProbability of Lower GI Source
HematemesisAlmost certainRare
MelenaProbablePossible
HematocheziaPossibleProbable
Blood-streaked stoolRareAlmost certain
Occult blood in stoolPossiblePossible
Table 2. Estimated Fluid and Blood Losses in Shock
Class 1Class 2Class 3Class 4
Blood Loss, mLUp to 750750-15001500-2000>2000
Blood Loss,% blood volumeUp to 15%15-30%30-40%>40%
Pulse Rate, bpm< 100>100>120>140
Blood PressureNormalNormalDecreasedDecreased
Respiratory RateNormal or IncreasedDecreasedDecreasedDecreased
Urine Output, mL/h>3530-4020-3014-20
CNS/Mental StatusSlightly



anxious



Mildly



anxious



Anxious,



confused



Confused,



lethargic



Fluid Replacement, 3-for-1 ruleCrystalloidCrystalloidCrystalloid and bloodCrystalloid and blood
Table 3. Effect of Number of Packed Erythrocyte Transfusions on Need for Surgery and Mortality from UGIB
Number of Units TransfusedNeed for Surgery, %Mortality Rate, %
044
1-3614
4-51728
>55743
Table 4. Effect of the Color of the Nasogastric Aspirate and of the Stool on UGIB Mortality Rate
Nasogastric Aspirate ColorStool ColorMortality Rate, %
ClearBrown or red6
Coffee-groundBrown or black8.2
Red19.1
Red bloodBlack12.3
Brown19.4
Red28.7
Table 5. Ulcer Characteristics and Correlations
Ulcer CharacteristicsPrevalence Rate, %Rebleeding Rate, %Surgery Rate, %Mortality Rate, %
Clean base4250.52
Flat spot201063
Adherent clot1722107
Visible vessel17433411
Active bleeding18553511
Table 6. Recurrent Ulcer and Postgastrectomy Syndromes After Operations for Duodenal Ulcer
Original OperationRecurrence Rate, %Postgastrectomy Syndrome Rate, %Mortality Rate, %
Proximal gastric vagotomy1050.1
Truncal vagotomy and drainage720-30< 1
Truncal vagotomy and antrectomy



Billroth I or Billroth II



130-500-5
Truncal vagotomy and antrectomy



Roux-en-Y



5-1050-600-5
Table 7. Effects of Operations for PUD on Gastric Emptying and Motility
OperationAntral InnervationLiquid EmptyingSolid Emptying
Proximal gastric vagotomyPreservedFastNormal
Truncal vagotomyDividedFastSlow
Truncal vagotomy and drainageDividedFastFast
Truncal vagotomy and antrectomyDividedFastFast
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