Upper Gastrointestinal Bleeding (UGIB) Clinical Presentation

Updated: Aug 12, 2019
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Presentation

History

The history and physical examination of the patient provide crucial information for the initial evaluation of persons presenting with a gastrointestinal (GI) tract hemorrhage. [5, 10] Important information to obtain includes potential comorbid conditions, medication history, and any prior history of GI bleeding, 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 upper GI bleeding (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 GI source of bleeding identified at urgent esophagogastroduodenoscopy. [27]

Patients may have a history of dyspepsia (especially nocturnal symptoms), ulcer disease, early satiety, and nonsteroidal anti-inflammatory drug (NSAID), antiplatelet therapy, 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 taking steroids, aspirin, dual antiplatelet therapy (DAPT) (eg, addition of clopidogrel to aspirin), or NSAID therapy. These high-risk individuals 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 there has not been successful eradication of an H pylori infection.

Patients may present asymptomatically or 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. Alcohol also interferes with cyclooxygenase (COX)-1 receptor enzymes which reduce the production of cytoprotective prostaglandin and alters gastric mucosal protection.

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 Physical Examination) [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

GI = gastrointestinal.

Next:

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.

Formal risk scoring systems have been validated and are becoming more widely utilized.

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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