Special Surgery 27. Symptomatics, Causes, and Treatments of Upper-Gastrointestinal Bleeding

I. Definition and Symptomatics

Definition

• UGIB: bleeding proximal to ligament of Treitz
• Source: esophagus, stomach, duodenum
• First question: stable or unstable?

Main Symptoms

• Hematemesis: vomiting blood

• Bright red → active / brisk bleeding
• Coffee-ground → blood altered by gastric acid

• Melena: black tarry stool → digested blood
• Hematochezia: rare in UGIB → brisk massive bleeding + rapid transit
• Epigastric pain: ulcer / gastritis clue
• Fatigue, dyspnea, pallor → chronic slow bleeding / anemia

Severity Clues

• Hypovolemia: dizziness, tachycardia, hypotension
• Severe bleeding: syncope, confusion, oliguria, shock
• Variceal clue: cirrhosis / portal hypertension signs

• Jaundice, ascites, spider naevi, splenomegaly
• Alcohol/viral hepatitis history
• Thrombocytopenia / INR elevation

II. Causes

Common Causes

1. Peptic ulcer disease: most common important cause

• Gastric or duodenal ulcer
• H. pylori / NSAIDs → ulcer → vessel erosion → bleeding

2. Esophageal / gastric varices

• Cirrhosis → portal hypertension → varices → massive bleeding risk

3. Mallory-Weiss tear

• Forceful vomiting/retching → GE-junction mucosal tear → bleeding

4. Gastritis / erosions / esophagitis

• Alcohol, NSAIDs, stress, H. pylori, reflux, infection in immunocompromised

5. Gastric cancer or other tumor

• Ulcerated tumor surface → chronic anemia or acute bleeding

6. Dieulafoy lesion

• Large submucosal artery → small mucosal defect → sometimes massive bleeding

III. Diagnosis

Initial Evaluation

• ABCDE + vital signs → hemodynamic status
• Physical exam: shock signs, abdominal tenderness, melena on DRE
• History: NSAIDs/aspirin, anticoagulants, previous ulcer/bleed

• Cirrhosis/alcohol → varices
• Forceful vomiting → Mallory-Weiss
• Weight loss/dysphagia/anorexia → cancer

• NG tube: not routine; may help selected cases

Laboratory Tests

• CBC: Hb/Hct, platelets
• Coagulation: INR/PT, aPTT
• Liver tests: cirrhosis / variceal suspicion
• BUN/creatinine ratio: often elevated in UGIB
• Type and screen / crossmatch

Definitive Diagnosis

• Upper endoscopy / EGD: gold standard

• Diagnostic + therapeutic
• Stable admitted UGIB → EGD within 24 h after resuscitation
• Unstable massive bleeding → urgent EGD after stabilization
• Suspected variceal bleeding → vasoactive drug + antibiotics first → EGD within about 12 h

IV. Treatment

1. Initial Stabilization

1. ABC → protect airway if massive hematemesis / confusion
2. Two large-bore IV lines → fluids → crossmatch blood
3. Transfuse if needed; usually restrictive strategy around Hb <7 g/dL
4. Monitor vitals + urine output
5. Hold/reverse anticoagulants if severe active bleeding
6. Correct clinically important coagulopathy / thrombocytopenia

2. Pharmacologic Treatment

• Suspected non-variceal UGIB: IV PPI

• Pantoprazole → acid reduction → clot stabilization

• Suspected variceal UGIB: octreotide / terlipressin

• Portal pressure ↓ → variceal bleeding ↓
• Cirrhosis: ceftriaxone antibiotic prophylaxis

• Peptic ulcer bleeding: stop NSAIDs if possible; test/eradicate H. pylori

3. Endoscopic Treatment

• Ulcer bleeding:

• Hemoclips
• Thermal coagulation
• Injection therapy, e.g. adrenaline + second modality

• Variceal bleeding:

• Esophageal varices → band ligation
• Sclerotherapy if banding not possible

4. Rescue / Other Interventions

• Refractory variceal bleeding:

• Balloon tamponade / esophageal stent → bridge only
• TIPS in selected or refractory variceal bleeding

• Recurrent non-variceal bleeding: repeat endoscopy → TAE if endoscopy fails
• Surgery: rare; failed endoscopy/IR, uncontrollable bleeding, perforated ulcer, bleeding tumor