eMedicine Specialties > Radiology > Vascular/Interventional

Gastrointestinal Bleeding, Upper

Author: Manish K Varma, MD, Chief of Interventional Radiology, Department of Radiology, Tripler Army Medical Center
Coauthor(s): Anthony W Allen, MD, Chief, Interventional Radiology, Brooke Army Medical Center; Associate Professor of Radiology, Uniformed Services University of the Health Sciences; Michael AJ Sawyer, MD, Director, Videoendoscopic Surgical Institute of Oklahoma, Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Lawton, Oklahoma
Contributor Information and Disclosures

Updated: Sep 10, 2008

Introduction

Background

Upper gastrointestinal bleeding (UGIB) is defined as hemorrhage that emanates proximal to the ligament of Treitz. It is a common and potentially life-threatening condition. More than 350,000 hospital admissions are attributable to UGIB, which has an overall mortality rate of 10%. Although more than 75% of cases of bleeding cease with supportive measures, a significant percentage of patients require further intervention, which often involves the combined efforts of gastroenterologists, surgeons, and interventional radiologists.^1,2,3,4

The first decision point in managing GI bleeding is defining the site and cause of bleeding: is it an upper GI or a lower GI hemorrhage?^5,6

Clinically, UGIB often causes hematemesis (vomiting of blood) or melena (passage of stools rendered black and tarry by the presence of altered blood). The color of the vomitus depends on its contact time with the hydrochloric acid of the stomach. If vomiting occurs early after the onset of bleeding, it appears red; with delayed vomiting, it is dark red, brown, or black. Coffee-ground emesis results from precipitation of blood clots in the vomitus. Hematochezia (red blood per rectum) usually indicates bleeding distal to the ligament of Treitz. Occasionally, rapid bleeding from an upper GI source may result in hematochezia.

The rate and extent of hemorrhage, coupled with the patient's comorbidities, determine the clinical presentation of UGIB. Endoscopy is a critical early intervention that can be used to establish the source of bleeding, and it also offers therapeutic options. If bleeding cannot be controlled by means of endoscopy, further interventions with catheter-directed embolotherapy or surgery may be warranted.⁷

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Gastrointestinal Bleeding.

Related eMedicine topics:
Upper Gastrointestinal Bleeding: Surgical Perspective
Lower Gastrointestinal Bleeding: Surgical Perspective
Pediatrics, Gastrointestinal Bleeding

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Specialty Site Gastroenterology
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CME Gastrointestinal Bleeding in the Elderly
CME SSRIs and Venlafaxine Linked to Greater Risk for Gastrointestinal Tract Bleeding

Pathophysiology

Upper gastrointestinal bleeding occurs from a variety of etiologies. The pathophysiology of the bleeding is often mucosal erosion with subsequent hemorrhage. About 90% of cases of UGIB arise from Mallory-Weiss tears, variceal hemorrhage due to portal hypertension, peptic ulcer disease, and gastritis.⁸

Prior to the introduction of H2-blockers, UGIB was mostly caused by peptic ulcer disease. Most of these ulcers occur in the duodenum. Gastritis, with subsequent gastric erosions and bleeding, is associated with recent alcohol ingestion, portal hypertension, or the use of anti-inflammatory drugs such as aspirin or ibuprofen (Motrin). Patients with severe underlying systemic disease, such as burns and trauma, and those who have undergone surgery may also have gastric erosions. Esophagogastric mucosal tears (Mallory-Weiss syndrome) are often preceded by retching or non-bloody vomiting that is followed by hematemesis.

Neoplasms from the esophagus, stomach, duodenum, or pancreas may result in UGIB because of mucosal erosion, neovascularity, and/or pseudoaneurysm formation. Arteriosclerotic aortic aneurysms may also rupture into the small intestine, often with fatal results.

Similarly, mucosal erosion is the etiology of Dieulafoy lesion. A Dieulafoy erosion is an abnormal cirsoid aneurysmal artery that protrudes through a tiny mucosal defect, usually within 6 cm of the gastroesophageal junction on the lesser curve of the stomach.

Angiodysplasia is an uncommon cause of UGIB. It may occur in the stomach or duodenum, often in young individuals, in whom the cause of the vascular malformation is developmental. In older individuals, the lesions are thought to develop as a result of chronic intermittent obstruction of the mucosal veins, which results in dilatation of the submucosal and mucosal veins.

Variceal bleeding from the esophagus or stomach is usually the result of portal hypertension secondary to cirrhosis. Although the precise etiology of variceal rupture is unknown, factors contributing to hemorrhage include erosion of the overlying mucosa by acid-peptic reflux, varix wall and esophageal mucosal thickness, and varix wall tension. Splenic vein occlusion is frequently caused by pancreatitis or pancreatic carcinoma. The blood from the spleen bypasses the obstruction through the left and right gastroepiploic veins, the short gastric and left gastric veins, and the arc of Barkow. The collaterals from the short gastric vein form gastric varices, which can cause gastric bleeding.

Trauma can result in direct hemorrhage from an upper GI source or subsequent pseudoaneurysm formation, which, by comparison, has an increased propensity to bleed. Hemobilia from iatrogenic causes, such as percutaneous biliary drainage and blunt or penetrating trauma, and a neoplasm may also cause UGIB.

Hemosuccus pancreaticus, bleeding into the pancreatic duct, is a rare cause of upper gastrointestinal bleeding. It is usually associated with chronic pancreatitis, pancreatic pseudocyst, and peripancreatic aneurysm, and is rarely seen in patients with a history of traumatic injury, familial pancreatitis, and neoplasia. Endoscopic retrograde cholangiopancreatography will demonstrate bleeding into the pancreatic duct. Treatment of the associated vascular lesion with selective embolization is usually successful.

Related Medscape topic:
Resource Center Peptic Ulcer Disease

Frequency

United States

More than 350,000 annual hospital admissions, or approximately 100 cases per 100,000 per year, occur because of upper gastrointestinal bleeding.

International

In the United Kingdom, the overall incidence of acute upper gastrointestinal hemorrhage is 103 cases per 100,000 adults per year.⁹ The findings of further studies from different countries are difficult to ascertain because of a paucity of large, retrospective studies and because of the use of indirect methods for calculation and estimation.

Mortality/Morbidity

• Morbidity: Patients with acute upper gastrointestinal bleeding commonly require hospitalization. The rate and extent of bleeding, advanced age, and comorbidities are key factors in determining the clinical outcome in UGIB. Although 75% of cases respond to conservative measures, a 10% mortality rate is associated with acute UGIB. After early conservative measures are undertaken, endoscopy is the study of choice. Endoscopic therapy has decreased the mortality rate from acute bleeding episodes, but the increasing age of the population and the increasing presence of comorbidities have not changed the overall mortality rate.
• Mortality: The overall mortality rate is estimated to be approximately 10% in the United States. The morbidity and mortality rates for UGIB are frequently associated with the underlying illness rather than with the bleeding itself. Despite advances in endoscopic and angiographic techniques that have lowered the morbidity rate associated with massive UGIB, the overall mortality rate has remained relatively stable because of the increasing age and presence of comorbidities in the population.

Race

No well-described racial predilection for upper gastrointestinal bleeding exists.

Sex

Studies from the United States and the United Kingdom have revealed a male-to-female ratio that is greater than that of other studies. The male-to-female ratio for upper gastrointestinal bleeding is approximately 2:1 in both countries. The mortality rates are similar in males and females.

Age

The number of cases of upper gastrointestinal bleeding increases with patient age. In a study performed in the United States, about 44.5% of all patients were aged 60 years or older. Morbidity and mortality rates also increased with age; 73.2% of deaths occurred in patients older than 60 years.¹⁰

Anatomy

Upper gastrointestinal bleeding arises from branches of the celiac artery and superior mesenteric artery (SMA), and rarely from aortointestinal fistula. Embolization and surgical procedures are relatively safe in terms of ischemic risk in this region because of the rich collateral network between the celiac artery and SMA, as well as between the branches of the celiac artery.

The left gastric artery arises from the celiac artery in 90% of individuals and supplies the stomach and distal esophagus. It is usually the first major branch of the celiac artery. It courses along the lesser curvature of the stomach and forms an anastomosis with the right gastric artery, which arises from the left hepatic artery (40%) or proper hepatic artery (40%). The right gastric artery supplies the pylorus and distal posterior surface of the stomach. The short gastric arteries (from the splenic artery) and the right and left gastroepiploic arteries (from the gastroduodenal artery [GDA] and splenic arteries, respectively) supply the greater curvature of the stomach.

The duodenum is supplied by the branches of the GDA and SMA, and occasionally from the hepatic arteries. A rich arterial communication exists between the GDA and SMA via the pancreatic arcade arteries and inferior pancreaticoduodenal artery. Thus, the angiographic evaluation of pyloroduodenal bleeding requires contrast material injections in both the celiac artery and SMA, as well as their branches.

Variceal bleeding often arises from esophageal or gastric varices from the coronary vein or short gastric veins in portal hypertension. Rarely, bleeding from varices in the small bowel may cause UGIB.

Presentation

In the vast majority of cases (>75%), upper gastrointestinal bleeding ceases with conservative measures. The first step in managing GI bleeding is determining the location: is the upper or lower tract involved? Clinically, the presence of hematemesis and melena are suggestive of bleeding proximal to the ligament of Treitz. Hematochezia often suggests bleeding from a lower GI source. However, a contact time of blood in the gut for 8 hours is required for melena and patients with rapid bleeding from an upper GI source pass bright red blood rectally because of rapid GI transit. Therefore, nasogastric (NG) tube aspiration and endoscopy is necessary if there is any question regarding the location of GI bleeding.

The clinical presentation of UGIB depends on the rate and duration of the bleed and the patient's underlying comorbidities. Blood loss of 500 mL is often required before systemic abnormalities appear. Greater blood loss can result in shock, with peripheral vasoconstriction and orthostatic hypotension (which implies significant volume depletion of >15%). Clinical symptoms include syncope, lightheadedness, nausea, sweating, tachycardia, and hypotension.

In the setting of acute blood loss, several laboratory values changes are observed. Obviously, the hematocrit level should decrease; however, the value may not be correlated with real blood loss because of hemodilution and equilibration with extravascular fluid. Mild leukocytosis and thrombocytosis often develop within 6 hours after the onset of bleeding. The blood urea nitrogen level may also be elevated in UGIB. This occurs because of the breakdown of blood proteins to urea by intestinal bacteria, coupled with a reduction in the glomerular filtration rate.

If an upper GI source is suspected, an NG tube is passed into the stomach. If red blood or a coffee-grounds appearance is found, saline irrigation is performed; this procedure allows estimation of the amount of bleeding and clears the stomach for subsequent endoscopy. If the initial lavage fluid is clear, the tube is kept in place for several hours, because duodenal bleeding may initially result in a clear NG aspirate. Resuscitative measures, including the placement of large-bore intravenous lines for volume repletion, are concurrently begun.

Preferred Examination

Upper endoscopy is the initial procedure of choice for the evaluation of acute upper gastrointestinal bleeding. Early endoscopy allows estimation of the rate of recurrent bleeding and enables various therapeutic options. It is also helpful in diagnosing and treating variceal bleeding. Recent studies have shown that early endoscopy is associated with lower healthcare costs and improved medical outcomes, compared with other procedures. However, upper GI endoscopic findings are nondiagnostic in about 10% of cases.^11,12,13,14

If endoscopy has failed to reveal a bleeding source or if the bleeding cannot be controlled, angiography is used for diagnosis and therapy. Angiography has been shown to depict the source with bleeding rates as low as 0.5 mL/min. If no active bleeding is identified angiographically in a patient with documented recurrent bleeding by endoscopy, prophylactic embolization of the left gastric artery or the gastroduodenal artery may be performed to control gastric or pyloroduodenal bleeding, respectively.

With advances in both endoscopic and angiographic techniques, surgical options are often limited in acute UGIB because of its morbidity and mortality rates. In the setting of recurrent variceal bleeding that is refractory to endoscopic control, the use of transjugular intrahepatic portosystemic shunts (TIPS) is preferred in the management of patients with a Child class B condition and in some with a Child class C condition. Currently, upper GI barium examinations have no role in the diagnosis of acute UGIB.

Limitations of Techniques

Endoscopy is often the first-line diagnostic examination and treatment option for upper gastrointestinal bleeding. However, findings can be nondiagnostic in about 10% of cases. For example, in the setting of massive UGIB, endoscopy may not be helpful because intraluminal blood cannot be adequately cleared. Angiography is limited by the rate of bleeding, which usually must be at least 0.5 mL/min before it is detected. Its accuracy in the detection of acute UGIB is 90%, and it is helpful in assessing occult UGIB.

A positive angiographic finding of bleeding is needed to initiate embolization, except in cases in which bleeding has been localized before — for example, in the left gastric artery (LGA) or gastroduodenal artery. In these situations, prophylactic embolization is helpful. Prophylactic embolization of the LGA without prior documented bleeding is advocated because almost 90% of patients with this condition survive if the bleeding is controlled. The left gastric artery is involved in 85% of cases of UGIB.

Differential Diagnoses

Duodenum, Ulcers
Esophagus, Tear
Gastric Carcinoma
Gastric Ulcer
Portal Hypertension

Other Problems to Be Considered

Peptic ulcer disease
Mallory-Weiss tears
Hemorrhagic gastritis
Esophageal varices
Aortoenteric fistula
Pseudoaneurysms
Dieulafoy vascular malformations
Hemobilia
Hemosuccus pancreaticus
Esophageal, gastric, duodenal, and pancreatic neoplasms
Angiodysplasia

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