eMedicine Specialties > General Surgery > Abdomen
Upper Gastrointestinal Bleeding, Surgical Treatment
Updated: Apr 11, 2006
Introduction
Acute gastrointestinal (GI) bleeding is a potentially life-threatening abdominal emergency that remains a common cause of hospitalization. The incidence of upper gastrointestinal bleeding (UGIB) is approximately 100 cases per 100,000 population per year (Fallah, 2000). Bleeding from the upper GI tract is approximately 4 times as common as bleeding from the lower GI tract and is a major cause of morbidity and mortality. Mortality rates from UGIB are 6-10% overall (Fallah, 2000).
An aging patient population with an increasing prevalence of associated medical comorbidities has kept the mortality figures largely unchanged for the past 30 years, despite technologic advances in endoscopy and other minimally invasive procedures (Peter, 1999). The use of various endoscopic techniques, medical therapies, and visceral angiography has progressively diminished the role of surgery in the emergent management of UGIB. Nevertheless, operative intervention still represents the most definitive intervention and remains the final therapeutic option for many bleeding lesions of the upper GI tract. Of patients who develop UGIB, 3-15% require a surgical procedure (Peter, 1999). With the evolution of laparoscopy, surgeons may have a new dimension to the management of GI tract bleeding by developing new techniques performed through smaller incisions.
Presentation
The history and physical examination provide crucial information for the initial evaluation of a patient presenting with a GI tract hemorrhage. The history findings can be extremely helpful in determining the location of the GI hemorrhage. Alcohol abuse or a history of cirrhosis should elicit consideration of portal gastropathy or esophageal varices as sources for the bleeding. A history of recent nonsteroidal anti-inflammatory drug (NSAID) abuse should elicit concern about bleeding from a gastric ulcer (Stabile, 2000).
- Differential diagnoses for UGIB
- Gastric ulcer
- Duodenal ulcer
- Esophageal varices
- Gastric varices
- Mallory-Weiss tear
- Esophagitis
- Neoplasm
- Hemorrhagic gastritis
- Dieulafoy lesion
- Angiodysplasia
- Hemobilia
- Pancreatic pseudocyst
- Pancreatic pseudoaneurysm
- Aortoenteric fistula
UGIB is defined as bleeding derived from a source proximal to the ligament of Treitz. Hematemesis and melena are the most common presentations of acute UGIB, and patients may present with both symptoms. Occasionally, a brisk UGIB manifests as hematochezia. A recent meta-analysis documented the incidence of presenting symptoms in patients with UGIB as follows (Peter, 1999):
- History and physical examination findings in acute UGIB at presentation
- 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%
As indicated, hematemesis is observed in 40-55% of patients, including patients with coffee-ground emesis. Melena is documented in approximately 70-80% of patients, and hematochezia is documented in approximately 15-20%. These clinical signs may also be indicators of the potential source of the GI bleeding, as noted in the following table (Peter, 1999).
Table 1. Probable Source of GI Bleeding Within the Gut
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Table
| 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 |
| 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 |
Some prognostic indicators that can be detected from the history and physical examination findings are helpful for developing a scoring system to assess the risk of poor outcome with UGIB. These factors include age, heart rate, systolic blood pressure (SBP) upon admission, orthostatic changes in blood pressure or pulse rate, and the use of any anticoagulants. 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 intensive care unit (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 such as ongoing brisk hematemesis or maroon or bright-red stools, which requires rapid blood transfusion.
Age older than 60 years is an independent marker for a poor outcome (Peter, 1999). The mortality rate increases to 12-25% in those older than 60 years compared to a mortality rate of less than 10% for patients younger than 60 years (Peter, 1999). The American Society for Gastrointestinal Endoscopy (ASGE) grouped patients with UGIB according to age and correlated age category to risk of mortality. The ASGE found a mortality rate of 3.3% for patients aged 21-31 years, a rate of 10.1% for those aged 41-50 years, and a rate of 14.4% for those aged 71-80 years (Peter, 1999).
Patients who present in hemorrhagic shock have an increased mortality rate of up to 30%. Hemorrhage may be classified based on the amount of blood loss, as noted in the following table (American College of Surgeons Committee on Trauma, 1997).
Table 2. Estimated Fluid and Blood Losses in Shock
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Table
| 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 |
| 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 |
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 pulse rate >100 bpm or SBP <100 mm Hg) with the incidence of rebleeding rates after initial nonsurgical intervention. 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 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 was able to correlate orthostatic changes with the incidence of mortality (Silverstein, 1981). 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.
Indications
See Surgical therapy for specific conditions.
Contraindications
See Surgical therapy for specific conditions.
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Further Reading
Keywords
UGIB, GI tract hemorrhage, GI bleeding, gastrointestinal bleeding, alcohol abuse, cirrhosis, portal gastropathy, esophageal varices, nonsteroidal anti-inflammatory drug abuse, NSAID abuse, gastric ulcer, peptic ulcer disease, PUD, Mallory-Weiss syndrome, Mallory-Weiss tear, Mallory-Weiss lesion, angiodysplasia, hereditary hemorrhagic telangiectasia, Rendu-Osler-Weber syndrome, Dieulafoy lesion, aortoenteric fistula, duodenal ulcer, Helicobacter pylori, H pylori, stress gastritis, portal hypertension, bleeding varices, variceal bleeding, variceal hemorrhage
