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

I. Definition, Classification and Symptomatics

Definition

Upper gastrointestinal bleeding (UGIB) = bleeding from GI tract proximal to ligament of Treitz
Sources: esophagus, stomach, duodenum
May be non-variceal or variceal
Clinical priority: assess hemodynamic instability before searching for exact cause

Classification

Non-variceal UGIB

Peptic ulcer disease
Erosive gastritis/duodenitis/esophagitis
Mallory-Weiss tear
Gastric/duodenal tumor
Dieulafoy lesion
Angiodysplasia / vascular ectasia

Variceal UGIB

Esophageal varices
Gastric varices
Portal hypertensive gastropathy

By clinical severity

Occult/chronic bleeding → iron deficiency anemia
Overt stable bleeding → hematemesis/melena without shock
Massive bleeding → shock, hematochezia, need for urgent intervention

Main Symptoms

Hematemesis:

Vomiting of blood
Bright red blood = active/recent brisk bleeding
Coffee-ground vomiting = blood altered by gastric acid

Melena:

Black, tarry, foul-smelling stool
Caused by digested blood
Usually suggests upper GI source, but can occur from small bowel/right colon bleeding

Hematochezia:

Fresh red blood per rectum
Usually lower GI bleeding
Can occur in massive brisk UGIB with rapid transit

Epigastric pain: typical in peptic ulcer disease/gastritis
Retching before bleeding: suggests Mallory-Weiss tear
Dyspepsia, NSAID history, previous ulcer history
Dysphagia, weight loss, anorexia: tumor warning signs

Signs of Severity

Hypovolemia:

Dizziness, weakness
Tachycardia
Hypotension
Orthostatic hypotension
Cold clammy skin
Delayed capillary refill
Oliguria

Severe bleeding:

Syncope
Confusion/agitation
Shock
Chest pain or dyspnea from demand ischemia/anemia

Chronic slow bleeding:

Fatigue
Dyspnea on exertion
Pallor
Iron deficiency anemia

Clues to Variceal Bleeding

Known cirrhosis or chronic liver disease
Jaundice, spider naevi, palmar erythema
Ascites, splenomegaly
Alcohol use disorder or viral hepatitis history
Thrombocytopenia, elevated INR, low albumin
Bleeding can be sudden and massive

II. Causes and Pathophysiology

Peptic Ulcer Disease

Most common important cause of non-variceal UGIB
Gastric or duodenal ulcer erodes into submucosal artery
Main risk factors:

Helicobacter pylori infection
NSAIDs and aspirin
Anticoagulants/antiplatelet drugs increase severity
Smoking
Severe physiological stress in ICU patients

Posterior duodenal ulcer can erode gastroduodenal artery → massive bleeding
Lesser curve gastric ulcer can erode branches of left gastric artery

Esophageal and Gastric Varices

Due to portal hypertension, most commonly liver cirrhosis
Portal hypertension → portosystemic collaterals → varices
High-risk features: large varices, red wale signs, advanced liver disease
Esophageal varices: treated mainly by endoscopic band ligation
Gastric varices: often treated with tissue adhesive/thrombin or radiological shunt/obliteration techniques depending on anatomy

Mallory-Weiss Tear

Longitudinal mucosal tear at gastroesophageal junction/cardia
Triggered by forceful vomiting, retching, coughing or seizure
Common with alcohol-related vomiting
Often self-limited
Endoscopic hemostasis if active bleeding or high-risk stigma

Erosive Disease

Erosive gastritis, duodenitis or esophagitis
Usually mucosal/oozing bleeding rather than arterial spurting
Causes:

NSAIDs/aspirin
Alcohol
Severe reflux esophagitis
Stress-related mucosal disease in ICU: burns, head injury, ventilation, coagulopathy
H. pylori
Infections in immunocompromised patients: CMV, HSV, Candida-associated ulceration

Malignancy

Gastric cancer, esophageal cancer, duodenal tumor, lymphoma, GIST
Bleeding from ulcerated/invasive tumor surface
Often chronic anemia, but can be acute
Red flags: weight loss, dysphagia, early satiety, anorexia, persistent vomiting
Endoscopic biopsy is required

Vascular Lesions

Dieulafoy lesion:

Large-caliber submucosal artery erodes through tiny mucosal defect
Often proximal stomach on lesser curvature
Can cause massive intermittent bleeding with normal surrounding mucosa
Treatment: clips/band/thermal combination endoscopic therapy

Angiodysplasia / vascular ectasia:

Fragile dilated mucosal vessels
Treated with argon plasma coagulation or other endoscopic coagulation

Gastric antral vascular ectasia (GAVE / watermelon stomach):

Chronic blood loss anemia
Associated with cirrhosis, systemic sclerosis, CKD

Rare Causes

Aortoenteric fistula:

Prior aortic graft/aneurysm history
Herald bleed followed by catastrophic bleeding
Needs emergency vascular surgery

Hemobilia:

Bleeding into biliary tree after trauma, liver biopsy, ERCP or tumor
Quincke triad: RUQ pain + jaundice + GI bleeding, uncommon complete triad

Hemosuccus pancreaticus:

Bleeding through pancreatic duct, often from pseudoaneurysm in pancreatitis

III. Diagnostics and Risk Stratification

Initial Evaluation

Assess ABC first
Airway risk:

Massive hematemesis
Altered consciousness
Ongoing active vomiting of blood
Consider endotracheal intubation before endoscopy in these patients

Vital signs:

Pulse, blood pressure, orthostatic change
Shock index = HR/SBP; high value suggests serious bleeding
Oxygen saturation, respiratory rate, temperature

Physical examination:

Abdominal tenderness or peritonitis
Digital rectal exam for melena/hematochezia
Signs of chronic liver disease
Stigmata of malignancy/cachexia

History:

NSAID/aspirin use
Anticoagulants, antiplatelets
Previous ulcer or GI bleed
Cirrhosis/portal hypertension
Alcohol use, vomiting/retching
Known aortic graft/aneurysm

Laboratory Tests

CBC:

Hemoglobin/hematocrit
Initial Hb can be falsely normal in acute hemorrhage
Platelet count

Coagulation profile: INR/PT, aPTT
Urea/creatinine:

BUN/creatinine ratio often elevated in UGIB due to digestion/absorption of blood and hypovolemia

Electrolytes, glucose
Liver tests, bilirubin, albumin if cirrhosis/varices possible
Blood gas/lactate if shock or severe bleeding
Type and screen/crossmatch
ECG/troponin in elderly, shock or coronary disease symptoms

Risk Scores

Glasgow-Blatchford Score (GBS):

Pre-endoscopy risk stratification
Uses BUN, Hb, blood pressure, pulse, melena, syncope, hepatic disease, cardiac failure
GBS 0-1 = very low risk; possible outpatient management with planned endoscopy depending on local pathway

Rockall score:

Predicts rebleeding/mortality, includes endoscopic diagnosis/stigmata

AIMS65:

Mortality risk tool: albumin, INR, mental status, SBP, age >65

Endoscopy

Upper endoscopy / EGD = diagnostic and therapeutic gold standard
Non-variceal UGIB:

Perform within 24 h after hemodynamic resuscitation in most admitted patients
Very urgent endoscopy is mainly for ongoing instability after resuscitation or massive active bleeding

Suspected variceal bleeding:

Endoscopy within 12 h after presentation/resuscitation
Do not wait for endoscopy before starting vasoactive drug and antibiotics

Pre-endoscopy erythromycin 250 mg IV 30-120 min before endoscopy can improve visualization in severe/ongoing bleeding
Nasogastric tube is not routine; may help in selected cases but does not exclude UGIB if clear

Endoscopic Stigmata: Forrest Classification for Ulcers

Forrest Type	Finding	Rebleeding Risk / Treatment
Ia	Spurting arterial bleeding	High risk; endoscopic hemostasis
Ib	Oozing bleeding	High risk; endoscopic hemostasis
IIa	Non-bleeding visible vessel	High risk; endoscopic hemostasis
IIb	Adherent clot	Consider clot removal and treat underlying stigma
IIc	Flat pigmented spot	Low risk; PPI, no endoscopic hemostasis usually
III	Clean base ulcer	Low risk; PPI, no endoscopic hemostasis

Other Diagnostics

CT angiography:

Useful if endoscopy cannot localize/control bleeding or aortoenteric fistula is suspected
Can guide transcatheter arterial embolization

Catheter angiography:

Diagnostic and therapeutic if active bleeding is present

IV. Treatment

Initial Stabilization

Airway, breathing, circulation
Call gastroenterology/endoscopy team early; surgeon/interventional radiology if massive or refractory bleeding
Two large-bore IV cannulas or central access
Crystalloid resuscitation if unstable
Crossmatch blood
Monitor vitals, ECG, mental status and urine output
NPO until endoscopy and stabilization

Transfusion and Correction of Hemostasis

Restrictive RBC transfusion strategy in most patients:

Transfuse around Hb <7 g/dL
Target Hb about 7-9 g/dL
Higher threshold/target if ongoing massive bleeding, shock, ischemic heart disease or severe comorbidity

Platelets:

Consider platelet transfusion in severe thrombocytopenia with active bleeding or procedure need

Anticoagulants:

Hold temporarily in significant active bleeding
Reverse life-threatening bleeding according to drug: vitamin K/PCC for warfarin, specific DOAC reversal where indicated/available
Restart after hemostasis based on thrombotic risk

Aspirin for secondary cardiovascular prevention:

Avoid prolonged interruption
Restart early after endoscopic hemostasis when bleeding is controlled

In cirrhosis, INR does not reliably reflect bleeding risk; avoid blind overcorrection with FFP unless clinically indicated

Non-Variceal Bleeding Treatment

Pharmacologic

High-dose IV proton pump inhibitor (PPI) before endoscopy if UGIB suspected
PPI must not delay endoscopy
After endoscopic hemostasis of high-risk ulcer:

High-dose PPI for 72 h: continuous infusion or high-dose intermittent regimen
Then oral PPI

Test for H. pylori in peptic ulcer bleeding
Eradicate H. pylori if positive and confirm eradication later
Stop NSAIDs if possible; use gastroprotection if antiplatelet/NSAID is unavoidable

Endoscopic Hemostasis

Indicated for active bleeding, visible vessel, and selected adherent clots
Methods:

Mechanical: clips, over-the-scope clip
Thermal coagulation
Injection therapy: dilute adrenaline/epinephrine
Topical hemostatic powder as rescue/temporary method in selected cases

Important rule: adrenaline injection should not be used as monotherapy for high-risk ulcers
Use adrenaline injection + second modality, or mechanical/thermal definitive therapy

Rebleeding / Failed Endoscopy

Repeat endoscopy with hemostasis if clinical rebleeding occurs
If repeat endoscopy fails → transcatheter arterial embolization (TAE)
Surgery if TAE unavailable or fails, or if perforation/malignancy needs operative treatment

Variceal Bleeding Treatment

Immediate Measures

Suspect variceal bleeding in any cirrhotic patient with UGIB
Start vasoactive drug immediately, before endoscopy:

Terlipressin, somatostatin or octreotide depending on availability
Continue usually 2-5 days

Start antibiotic prophylaxis from admission:

Ceftriaxone commonly used in advanced cirrhosis or high quinolone-resistance settings
Reduces infection, rebleeding and mortality

Restrictive transfusion: target Hb about 7-8 g/dL unless special indication
Avoid overtransfusion because it can increase portal pressure and rebleeding
Endoscopy within 12 h after resuscitation

Endoscopic and Rescue Therapy

Esophageal varices:

Endoscopic variceal band ligation = first-line endoscopic therapy
Sclerotherapy if banding not technically possible

Gastric varices:

Tissue adhesive/thrombin injection for many gastric variceal bleeds
TIPS or BRTO-type radiological approaches in selected anatomy/centers

Refractory bleeding:

Balloon tamponade or self-expanding esophageal metal stent as temporary bridge
Definitive rescue: covered TIPS

Pre-emptive/early TIPS within 72 h, ideally <24 h, for selected high-risk patients:

Child-Pugh C <14
Or Child-Pugh B >7 with active bleeding at initial endoscopy

Surgical Role

Surgery is now uncommon in UGIB because endoscopy and interventional radiology are effective
Indications:

Persistent life-threatening non-variceal bleeding after failed endoscopy and TAE unavailable/failed
Perforated bleeding ulcer
Bleeding tumor requiring resection or palliation
Aortoenteric fistula: emergency vascular surgery

Examples:

Oversewing bleeding duodenal ulcer + ulcer operation when indicated
Gastrotomy and oversewing bleeding gastric vessel/ulcer
Gastrectomy for selected uncontrolled gastric bleeding or cancer

Exam-Focused Algorithm

Hematemesis/melena → ABC, IV access, fluids, crossmatch, labs
Assess shock and airway; intubate if massive hematemesis or altered consciousness
Use GBS for pre-endoscopy risk; GBS 0-1 can often be outpatient pathway
Start IV PPI for suspected non-variceal UGIB
If cirrhosis/varices possible: add vasoactive drug + ceftriaxone immediately
Endoscopy after resuscitation: within 24 h non-variceal; within 12 h suspected variceal
Endoscopic hemostasis according to cause: clip/thermal/injection combination for ulcer, banding for esophageal varices
Rebleeding: repeat endoscopy → TAE/TIPS depending on non-variceal vs variceal source → surgery only if rescue methods fail or special cause