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UPPER GI BLEEDING

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Gastrointestinal (GI) bleeding accounts for a significant number of hospitalizations every year with a median length of stay of 4 days and with greater than 30% of patients requiring intensive care unit (ICU) care.1 Early diagnosis of the cause and appropriate intervention can significantly reduce ICU and hospital stays and improve morbidity and mortality. This chapter focuses on a discussion of the differential diagnosis of upper and lower GI bleeding and management principles.

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KEY POINTS

  1. The first step in the management of upper GI bleeding (UGIB) is to assess hemodynamic status and resuscitate if there is any instability. Restricted transfusion strategies (transfusion for hemoglobin [Hb] < 7) yield better outcomes than aggressive transfusion strategies.

  2. Patients should be stratified for risk of rebleeding and mortality based on clinical predictors and endoscopic findings.

  3. Early endoscopy (within 24 hours) for UGIB improves outcomes and length of hospital stay; endoscopic treatment is warranted for high-risk lesions (active bleeding vessel, oozing vessel, visible vessel). Angiography with embolization or surgery can be used as rescue therapy for patients who fail endoscopic therapy.

  4. Patients with acute hemorrhage suspected from varices should undergo early endoscopy and endoscopic band ligation for treatment of varices that have stigmata of bleeding; transjugular intrahepatic portosystemic shunting (TIPS) can be used as rescue therapy for patients who fail endoscopic therapy.

  5. Pharmacologic therapy in conjunction with endoscopic therapy can improve rebleeding rates and survival.

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INTRODUCTION

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UGIB has an incidence of 48 to 160 cases/100,000 adults per year.2 Bleeding from an upper GI source is defined by overt presentation of bleeding represented as melena, hematemesis, or occasionally hematochezia, with localization of the bleeding lesion to the esophagus, stomach, or duodenum. UGIB is 5 to 6 times more common than lower GI bleeding (LGIB). The clinical presentation of UGIB can vary widely from clinically insignificant bleeding to life-threatening bleeding. Mortality from UGIB is generally between 10% and 14%.3 The management principles of UGIB focus on the risk stratification of patients and the early diagnosis and treatment of underlying causes.

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HISTORY

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UGIB is generally described as the presentation of melena, black tarry stools, or the description of hematemesis, vomiting of blood. The presentation may be insidious in onset or abrupt. Details obtained on history will suggest the duration of the bleeding and whether it is acute or chronic. Patients will often describe the presence of diarrhea associated with UGIB because blood passing through the GI tract often results in multiple loose bowel movements. Rapid UGIB may present as hematochezia (bright red blood or maroon stools from below) in addition to melena. Approximately 10% of patients with hematochezia may have upper GI sources of their bleeding.

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Symptoms that accompany UGIB may reflect significant hemodynamic compromise; these include dizziness, light-headedness, chest pain, shortness of breath or dyspnea on exertion, weakness, or fatigue. Symptoms such as chest pain or shortness of breath suggest a more acute ...

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