Approach Considerations
A complete blood cell (CBC) count with platelet count and differential is necessary to assess the level of blood loss in a patient with upper gastrointestinal (GI) bleeding (UGIB). Where possible, having the patient's previous results as a baseline is useful to gauge this loss. The CBC count should be checked frequently (every 4-6 h initially), depending on the severity of the bleeding, clinical stability, and apparent rate of blood loss.
Assessing patients' calcium levels is useful in identifying individuals with hyperparathyroidism, but it is especially helpful in monitoring calcium in patients receiving multiple transfusions of citrated blood. Hypercalcemia increases acid secretion.
A gastrin level may identify the rare patient with gastrinoma as the cause of UGIB and multiple ulcers. It is important to recognize that moderately high elevations of gastrin are seen in patients taking proton pump inhibitors (PPIs).
Electrocardiography (ECG) should be considered, especially in those with underlying cardiac disease or risk factors. Close measurement of vital signs, including continuous pulse and blood pressure monitoring, is important and may alert clinicians to important changes in the patient's clinical stability. Careful and ongoing monitoring of volume resuscitation is essential to avoiding end-organ injury, especially acute myocardial infarction due to hypotension.
It is critical to use a multidisciplinary approach in patients with severe UGIB. Intensivists, primary care providers, surgeons, interventional radiologists, and cardiologists may all play an essential role, depending on the presence of patients' comorbidities and their clinical course.
See Upper Gastrointestinal Bleeding Imaging and Esophageal Varices Imaging for more information.
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. [41]
Table 2. Estimated Fluid and Blood Losses in Shock (Open Table in a new window)
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 |
bpm = beats per minute; CNS = central nervous system |
||||
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 systolic blood pressure [SBP] < 100 mm Hg) with the incidence of rebleeding rates after initial nonsurgical intervention. [41] 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 American Society for Gastrointestinal Endoscopy (ASGE) survey was able to correlate orthostatic changes with the incidence of mortality. [42] 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.
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 in patients with suspected upper gastrointestinal (GI) bleeding (UGIB). 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. [43, 44]
According to the 2008 Scottish Intercollegiate Guidelines Network (SIGN) guideline, patients in shock should receive prompt volume replacement. [45]
However, once the patient has been stabilized, controversy exists regarding strategies for transfusion of red blood cells in GI bleeding, with some studies suggesting improved outcomes with a more judicious use of blood transfusions. In a study that compared the efficacy and safety of a restricted transfusion strategy with those of a liberal transfusion strategy in 921 patients with severe acute UGIB, Villanueva et al concluded that a restrictive strategy (n = 461) significantly improved outcomes in patients with acute UGIB compared with that of a liberal transfusion strategy (n = 460). [43] In the restrictive strategy, patients were transfused when their hemoglobin level fell below 7 g/dL; in the liberal strategy, patients were transfused when their hemoglobin level fell below 9 g/dL.
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. [25] Operative intervention may be indicated once the blood transfusion number reaches more than 5 units, as noted in the following table. [25]
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 Transfused |
Need for Surgery, % |
Mortality, % |
0 |
4 |
4 |
1-3 |
6 |
14 |
4-5 |
17 |
28 |
>5 |
57 |
43 |
BMP, BUN, and Coagulation
The basic metabolic profile (BMP) is useful in evaluating for renal comorbidity in cases of suspected upper gastrointestinal (GI) bleeding (UGIB); 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 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 (PTT), and international normalized ratio (INR) should be checked to document the presence of coagulopathy. The coagulopathy may be consumptive and associated with a thrombocytopenia.
In a retrospective institutional study, multivariate logistic regression revealed that concomitant antiplatelet therapy, timing of esophagogastroduodenoscopy (EGD) within 12 hours of presentation, and INR level were independent predictors of identification of a source of bleeding. [46] At a threshold of INR 7.5 at presentation, the likelihood of finding an endoscopically significant lesion was less than 20%. The investigators indicated that the relationship between INR elevation and identification of a bleeding source or endoscopic intervention at EGD were antiparallel, but regardless of source identification or endoscopic intervention, important clinical outcomes were unchanged. [46]
A platelet count below 50 × 109 cells/L with active acute hemorrhage may warrant a platelet transfusion and fresh frozen plasma in an attempt to replace lost clotting factors.
The coagulopathy could be a marker of advanced 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.
Risk Scoring
Many tools are used to stratify the severity of bleeding in patients presenting with an acute upper gastrointestinal (GI) bleed (UGIB). Several use the blood urea nitrogen (BUN) or the BUN-to-creatinine ratio as part of the formula when calculating the bleeding risk. The primary goals are to identify those who are at high risk for severe bleeding that requires hospital admission, the necessity of endoscopic intervention, the need for triage to intensive care unit (ICU) admission, the risk for rebleeding, and mortality. [47, 48]
The modified Glasgow-Blatchford bleeding score (GBS) and the Rockall bleeding score are the two systems most commonly used for estimating in-hospital mortality in UGIB. These tools utilize both pre- and post-endoscopy components for scoring. The GBS score helps to identify patients at lower risk for severe bleeding and who might be managed as an outpatient. The Rockall score and the more recent AIMS65 score (A lbumin < 3.0 g/dL, I nternational normalized ratio [INR] >1.5, altered M ental status, S ystolic blood pressure ≤90 mm Hg, and age >65 y), [49, 50, 51] reliably predict mortality. [52]
The Progetto Nazionale Emorragia Digestiva (PNED) system, a very complex and relatively new tool, is thought to not only be more selective for classifying a case as severe but also to have a greater predictive capacity for mortality compared with the Rockall score. [53]
Each of these tools is becoming a common component in the risk-stratifying process in current practice for assessing the severity of GI bleeding, triage, and role for endoscopic intervention. [50, 51, 54]
Endoscopy
The development of endoscopy has provided clinicians with the ability for diagnostic and therapeutic approaches to bleeding from the gastrointestinal (GI) tract. Endoscopic examination of the upper GI tract provides useful information regarding the source and site of bleeding. [42, 55, 56]
Endoscopic findings and their incidence rate in patients with upper GI bleeding (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 intensive care unit (ICU) setting have been achieved. Optimize conditions for performing endoscopy, including involvement of multidisciplinary support, obtaining appropriate informed consent, and ensuring the availability of appropriate equipment and personnel. Endoscopy typically takes place within 24 hours. Early studies have shown that emergent endoscopy, within 12 hours or less from presentation, may reveal a higher-risk stigmata of bleeding on endoscopy and require therapeutic intervention, but other clinical endpoints such as the need for surgical intervention, length of stay, and mortality are not significantly impacted. [57, 58, 59]
Although not a widely available or commonly employed modality in the setting of acute UGIB, capsule endoscopy (CE) may identify low-risk lesions in UGIB, potentially allowing a subset of patients to be safely treated as outpatients. In a study of CE in patients with UGIB, of those with duodenal visualization on CE, 23 of 25 (92%) CE findings were concordant with esophagogastroduodenoscopy (EGD) for low-risk lesions that would have been candidates for outpatient management. [60] A cause for bleeding was identified in 62 (75%) patients. CE and EGD findings were concordant in 34 (55%) patients. Among the patients with positive EGD findings, 21 (38%) had negative CE results. Of these, 7 were a result of a lack of duodenal visualization. Of 28 patients with normal EGD results, 7 (25%) had positive CE results. [60]
Chest Radiography
If clinical suspicion is high for aspiration pneumonia, effusion, or esophageal perforation, order chest radiographs to rule out these conditions. Obtain abdominal scout and upright films to exclude a perforated viscus and ileus.
Barium contrast studies are not usually helpful in cases of suspected upper gastrointestinal bleeding and can make endoscopic procedures more difficult (ie, white barium obscuring the view) and dangerous (ie, risk of aspiration).
See Upper Gastrointestinal Bleeding Imaging and Esophageal Varices Imaging for more information on these topics.
Computed Tomography Scanning
Computed tomography (CT) scanning and ultrasonography may be indicated for the evaluation of liver disease for cirrhosis, cholecystitis with hemorrhage, pancreatitis with pseudocyst and hemorrhage, aortoenteric fistula, and other unusual causes of upper gastrointestinal (GI) hemorrhage (UGIB). [2] The 2010 American College of Radiology (ACR) criteria state that CT scanning is particularly useful for localizing obscure UGIB and for evaluating a patient with UGIB and a history of aortic reconstruction or pancreaticobiliary procedure. [61]
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 the aortic graft.
CT angiography (CTA) holds promise as an initial test for acute GI bleeding because of its ubiquity, rapid performance, and potential to offer diagnostic information for management guidance. [62] CTA has the potential advantage of precisely localizing the source of GI bleeding, and to diagnose underlying pathology that may be the cause of bleeding to direct future management. Moreover, CTA can often identify causes of GI bleeding outside the GI tract (eg, hemobilia). In addition, CTA can not only define the underlying vascular anatomy before patients undergo transcatheter angiography embolization but also identify any anatomic variants that may affect management. [62]
See Upper Gastrointestinal Bleeding Imaging and Esophageal Varices Imaging for complete information on these topics.
Nuclear Medicine Scanning
Nuclear medicine scans may be useful in determining the area of active hemorrhage. Radionuclide imaging for gastrointestinal (GI) bleeding is generally performed with technetium-99m (99mTc)-tagged red blood cells, with an initial injection of radiotracer and subsequent gamma camera imaging. GI bleeding can be identified with visualization of radiotracer activity outside of normal areas of blood pool, which either focally intensifies or moves over time in an antegrade or retrograde manner. In addition, radionuclide studies are highly sensitive: They can detect rates of bleeding as low as 0.05–0.1 mL/minute as well as detect arterial and venous hemorrhages. [62]
However, this imaging modality has a prolonged imaging time and is therefore not ideal for clinically unstable patients. Radionuclide scans also frequently fail to precisely anatomically localize the site of active bleeding. [62] Nonetheless, radionuclide scanning maintains some appeal as a noninvasive strategy in evaluating GI bleeding. However, the 2010 American College of Radiology (ACR) criteria state that 99mTc-labeled erythrocyte scans are of limited value in diagnosing upper GI bleeding (UGIB), but continue to be useful in certain cases of obscure UGIB. [61]
Angiography
Angiography may be useful if bleeding persists and endoscopy fails to identify a bleeding site. According to the 2010 American College of Radiology (ACR) guidelines, angiography along with transcatheter arterial embolization (TAE) should be considered for all patients with a known source of arterial upper gastrointestinal (GI) bleeding (UGIB) that does not respond to endoscopic management, or in patients with active bleeding and a negative endoscopy. [61]
In clinically unstable patients, angiography should be considered the preferred diagnostic and therapeutic strategy after failed endoscopy, as it has favorable clinical outcomes compared with emergent surgery for UGIB. [63, 64]
There are highly variable sensitivity and specificity data for catheter angiography in the literature, with sensitivity averaging 60%, [63] as well as a 60%-100% technical success rate for UGIB (73%-100% for lower GI bleeding). [39] Angiography not only has a high spatial resolution and can detect rates of bleeding as low as 0.5 mL/min, [65] but it also has the added major advantage of allowing for treatment of GI bleeding with embolization therapy. However, its primary disadvantage is that it is an invasive and time-consuming procedure with a potentially high radiation dose. In addition, patients may have falsely negative findings in the presence of intermittent GI bleeding and if there is no active bleeding during the angiogram. [62]
In cases of aortoenteric fistula, angiography requires active bleeding (1 mL/min) to be diagnostic.
Multidetector CTA
Multidetector CT angiography (MDCTA) has increasingly been adopted for the diagnosis of acute GI bleeding. [66] Because CT scanning can be acquired rapidly and is nearly universally available in the acute setting, it may be an ideal initial diagnostic test for patients who are unstable with UGIB or lower GI bleeding with failed endoscopy or have a source of bleeding seen on an additional imaging modality. [67]
CTA appears to have a high negative predictive value (NPV) for the identification of obscure GI bleeding that may be useful for excluding patients who are unlikely to benefit from transcatheter mesenteric angiography. [68] In a retrospective study of 20 patients who underwent 20 negative CTA evaluations to assess and treat GI bleeding followed by mesenteric angiography (MA), 18 of the 20 patients also had negative subsequent MA (NPV = 90%). [68] The remaining two cases were false negatives, with UGIB (P < 0.05). The authors concluded CTA may be considered as a first-line diagnostic study for evaluating obscure GI bleeding, and this diagnostic modality could avoid the associated costs, risks, and challenges associated with transcatheter mesenteric angiography. [68]
Nasogastric Lavage
Nasogastric lavage may confirm recent upper gastrointestinal (GI) bleeding (UGIB) (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. [69]
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 in the aspirate with red stool is associated with an increased mortality rate from more active bleeding compared with negative aspirate findings with brown stool.
More recent evidence-based guidelines suggest that nasogastric or orogastric lavage is not required in patients with UGIB, but either can be used for diagnosis, prognosis, visualization, or therapeutic effect. [65]
Documentation of an upper GI source
Nasogastric aspirates with blood or coffee-ground material are clear indications of UGIB, and a bloody nasogastric aspirate raises the likelihood of the presence of active bleeding or a nonbleeding visible vessel, as compared to coffee-grounds or a clear nasogastric aspirate. However, a clear or bile-stained nasogastric aspirate may be seen in up to 15%-18% of patients with an upper GI source. [70] In addition, testing nasogastric aspirates for occult blood has not been proven to be useful.
Prognostic value
Intuitively, a persistently bloody nasogastric aspirate would seem likely to indicate a more severe UGIB episode. A report indicates that a nasogastric aspirate with red blood is associated with more severe bleeding (proportion requiring >5 units of blood and surgery) and raises the likelihood of identifying high-risk stigmata at endoscopy. [70]
Improvement of visualization
The standard small 16-18 gauge nasogastric tube typically used for aspiration is not likely to effectively clear clots from the stomach, despite vigorous lavage. A large-bore orogastric tube is more likely to be successful in clearing the stomach, but the use of a large-bore orogastric tube is difficult and uncomfortable for patients and cannot be recommended routinely.
With regard to therapeutic effect, older surgical literature reported that nasogastric lavage could stop bleeding in a majority of cases and also recommended the use of iced saline. However, UGIB stops spontaneously in most patients without specific therapy, and canine studies with experimentally induced ulcers have indicated that results with lavage are no better, and may even be worse, at temperatures of 0°-4°C (32°-39.2°F) [65] as a result of disruption of the clotting cascade. Patients are invariably uncomfortable with nasogastric tubes in general and often are uncomfortably chilled with cold lavage attempts.
Histologic Findings
In patients with gastric ulcers, the bleeding vessel lies in the deepest layer of the ulcer. Fibrinoid necrosis is observed at the site of perforation of the vessel. Pseudoaneurysmal dilatation 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.
However, histologic findings may not offer clinically relevant information in the initial management of upper gastrointestinal (GI) bleeding (UGIB), in part due to the delay in processing of pathologic specimens from the time of the initial esophagogastroduodenoscopy (EGD) and endoscopic biopsies.
Previous reports have noted a decreased sensitivity of biopsies for H pylori during acute GI bleeding, presumed to be due to the buffering effects of blood. [71, 72] This was true primarily for the rapid urease testing. However, histology is not affected by the presence of blood at endoscopy in the diagnosis of H pylori. [73]
-
Upper gastrointestinal bleeding (UGIB). Ulcer with active bleeding.
-
Upper gastrointestinal bleeding (UGIB). Ulcer with a clean base.
-
Upper gastrointestinal bleeding (UGIB). Diagram of an ulcer with a clean base.
-
Upper gastrointestinal bleeding (UGIB). Ulcer with an overlying clot.
-
Upper gastrointestinal bleeding (UGIB). Ulcer with a visible vessel.
-
Upper gastrointestinal bleeding (UGIB). Diagram of an ulcer with a visible vessel.
Tables
- Table 1. Probable Source of GI Bleeding Within the Gut
- Table 2. Estimated Fluid and Blood Losses in Shock
- Table 3. Effect of Number of Packed Erythrocyte Transfusions on Need for Surgery and Mortality from UGIB
- Table 4. Effect of the Color of the Nasogastric Aspirate and of the Stool on UGIB Mortality Rate
- Table 5. Ulcer Characteristics and Correlations
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. |
||
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 |
bpm = beats per minute; CNS = central nervous system |
||||
Number of Units Transfused |
Need for Surgery, % |
Mortality, % |
0 |
4 |
4 |
1-3 |
6 |
14 |
4-5 |
17 |
28 |
>5 |
57 |
43 |
Nasogastric Aspirate Color |
Stool Color |
Mortality, % |
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 |
|
UGIB = upper gastrointestinal bleeding. |
||
Ulcer Characteristics |
Prevalence Rate, % |
Rebleeding Rate, % |
Surgery Rate, % |
Mortality, % |
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 |
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