Upper Gastrointestinal Bleeding

Upper gastrointestinal (GI) bleeding refers to bleeding that

occurs anywhere in the esophagus, the stomach, or the upper
part of the small intestine. It is a symptom of an underlying
disorder, and it can be serious.
1. Brief description of the disease

Occur when part of the upper digestive tract becomes injured or inflamed. A GI bleed is
a symptom of another disorder rather than a health condition in itself. Upper GI bleeds can
occur in the esophagus, stomach, and duodenum, the initial part of the small intestine. A GI
bleed can be acute or chronic.
Acute bleeds- sudden and severe;
chronic- lasts longer, less obvious.
Both can cause serious health complications if not treated.

2. Etiology/Cause
a. Peptic Ulcer- are sores that develop on the lining of the stomach and the upper portion
of the small intestine (duodenum). They typically result from a:
i. Helicobacter pylori infection or
ii. Nonsteroidal anti-inflammatory drugs (NSAIDs)- such as aspirin or ibuprofen
b. Esophagitis- inflammation of the esophagus; most commonly caused by GERD; can also
occur due to medications, infection, allergies
c. Enteritis- occurs when the small intestine becomes inflamed (bacterial or viral infection);
can also be due to radiation therapy, certain meds, alcohol, inflammatory bowel disease
d. Mallory-Weiss tears- tears in the lining of the esophagus that often occur as a result of
prolonged vomiting or coughing; can cause a lot of bleeding; sometimes heal on their
own
e. Esophageal varices- are enlarged veins that can develop at the lower end of esophagus;
most common I people with liver disease, such as cirrhosis; do not usually have
symptoms unless the veins begin to bleed
f. Gastritis- inflammation of the stomach; over time can cause ulcers or damage parts of
the stomach lining, leading to bleeding; can occur due to NSAID use, injury, IBD, or
infection.
g. Cancer- less common cause of UGIB

3. Clinical manifestations
a. Hematemesis- vomiting of blood or coffee-ground-like material
i. suggests bleeding proximal to the ligament of Treitz;
ii. The presence of frankly bloody emesis suggests moderate to severe bleeding
that may be ongoing,
iii. whereas coffee-ground emesis suggests more limited bleeding.
 b. Melena- black, tarry stools
i. The majority of melena originates proximal to the ligament of Treitz (90
percent),
ii. though it may also originate from the oropharynx or nasopharynx, small bowel,
or colon
iii. Melena may be seen with variable degrees of blood loss, being seen with as
little as 50 mL of blood
c. Hematochezia- red or maroon blood in the stool
i. is usually due to lower GI bleeding.
ii. However, it can occur with massive upper GI bleeding, which is typically
associated with orthostatic hypotension.
d. Stomach cramps
e. Unusually pale skin
f. Feeling faint, dizzy, or tired
g. Weakness
h. Occult bleeding- blood in the stool that is not visible; can only be detected using a stool
test.

Acute GI bleeds can lead to shock. Symptoms are:

- a rapid pulse
- a drop in blood pressure
- little to no urination
- unconsciousness

Chronic GI bleed is slower bleeding that can last a long time, may come and go. It can
lead to significant health complications, such as anemia.

4. Diagnostic Procedures

Initial Evaluation- history, physical examination, laboratory tests

Goal of evaluation:
i. assess the severity of the bleed
ii. identify potential sources of the bleed
iii. determine if there are conditions present that may affect subsequent management

a. Stool tests: These can detect inflammation, occult bleeding, or infections, such as H.
pylori.
b. Blood tests: These tests can reveal anemia.
c. Upper endoscopy or enteroscopy: A doctor passes an endoscope down the esophagus
to view the stomach or small intestine.
d. Gastric lavage: This procedure involves removing the contents of the stomach to
determine the source of any bleeding.
e. A biopsy: A doctor will take a small sample of tissue from an affected area and send it to
a lab for analysis.
 f. Imaging tests: Examples include CT scans and barium X-rays.

5. Risk Factors (Modifiable/Non-modifiable)

a. Hemodynamic instability (systolic blood pressure less than 100 mmHg, heart rate
greater than 100 beats per minute)
b. Hemoglobin less than 10 g/L
c. Active bleeding at the time of endoscopy
d. Large ulcer size (greater than 1 to 3 cm in various studies)
e. Ulcer location (posterior duodenal bulb or high lesser gastric curvature)

6. Pathophysiology
UGIB is defined as bleeding derived from a source proximal to the ligament of Treitz, a
duodenal suspensory ligament that attaches to the junction of the duodenum and
jejunum, separating the upper and lower GI tract (see Ligament of Treitz). This includes
bleeding from the esophagus, stomach, or duodenum.
 Peptic ulcer disease (PUD). The most common cause of UGIB, PUD accounts for 62% of all cases
and includes both gastric and duodenal ulcers. 6,7 Smoking, alcohol, and nonsteroidal anti-
inflammatory drugs (NSAIDs) can also contribute to PUD bleeding. 4,7
 NSAIDs. Gastric injury from NSAIDs accounts for approximately 20% of UGIB. 3 Bleeding due to
acute or chronic NSAID use is a common adverse reaction among older adults and in those who
have been prescribed anticoagulants and steroids. As NSAIDs are highly acidic, acute and chronic
use may cause severe irritation of the gastric mucosa and block the protective mechanisms that
help maintain its integrity.8
 Esophagogastric varices are associated with dilated esophageal and gastric veins due to portal
hypertension.3 In the US, alcoholic cirrhosis is the most common cause of portal hypertension,
and the vast majority of patients with esophagogastric varices have cirrhosis. 3,6 These varices can
rupture and cause acute hemorrhage.
 Mallory-Weiss tears are longitudinal mucosal lacerations in the distal esophagus and proximal
stomach that occur due to profuse and forceful vomiting or gagging. Patients may be at risk for
developing Mallory-Weiss tears as a result of alcohol abuse and/or gastritis and esophagitis. 4,6

7. Nursing Management
When caring for patients with UGIB, nurses should take the following precautions to
ensure high-quality care:

Establish adequate venous access. If bleeding is suspected, insert at least two large-bore
I.V. catheters in case blood products, fluid resuscitation, and/or medications are
required.
Prepare to administer supplemental oxygen as prescribed.
Administer blood products as prescribed.
Monitor vital signs frequently to assess for hemodynamic instability.
Accurately document intake and output, including emesis and liquid stools.
Prepare patients for any diagnostic studies, including upper endoscopy.
Administer medications as prescribed.
 Monitor lab study results, including hemoglobin, hematocrit, platelet counts, and
electrolyte levels.
Assess for adequate urinary output with a goal of at least 0.5 mL/kg/h.

8. Surgical Management
a. Upper GI endoscopy- performed on patients with suspected ongoing active bleeding
after resuscitation within 12 hours

Where the causes are confirmed as peptic ulcer, gastric erosions due to alcohol and NSAIDs, gastric varices,
Mallory-Weiss tear, angiodysplasia and gastric cancer the following surgeries are recommended:
Under-running the ulcer : Peptic ulcers usually stop bleeding spontaneously. But when non-operative
methods fail, surgery becomes the only option for a life-threatening situation. The simplest way to stop an
ulcer from bleeding is to by underrunning it. The surgery is done under general anesthesia. The laparoscopic
procedure involves making a 11mm port just under the xiphisternum. 2 to 3 stitches are passed deep into the
ulcer and the sutures are tied tight to stop the bleeding. A major part of the procedure involves just looking for
the peptic ulcer which is an extremely tedious and meticulous process.
Pyloroplasty : A pyloroplasty is done to open the lower part of the stomach, a thick, muscular area called the
pylorus. Under general anesthesia, a laparoscopic surgery requires three small incisions in the area that connect
the stomach and the duodenum. Some of the thickened muscle of the pylorus is divided laterally and cut
through to widen it making the connection larger. There are at least three types of pyloroplasty:

 Jaboulay pyloroplasty Without pylorus incision – side to side gastroduodenostomy

 Heineke Mikulicz pyloroplasty longitudinal incision transversely across the pylorus – common
procedure
 Finney pyloroplasty With pylorus incision – side to side gastroduodenostomy

Partial gastrectomy : This procedure involves removal of part of the stomach. The procedures are performed
under general anesthesia. A midline incision from the xiphoid process to the umbilicus and self-retaining
subcostal retractors the upper abdomen is explored for metastasis. The part of the stomach is resected and
gastroduodenal anastomosis is achieved after duodenal and omental mobilizations.
Total gastrectomy : This procedure aims at cutting into the abdomen to resect all of the stomach. A midline
incision or a bilateral subcostal incision inferior to the umbilicus is made exposing the stomach and distal
esophagus. Self-retaining retractors provide a wider exposure. The stomach is retracted and the esophagus is
directly connected to the small intestine.
Vagotomy : The vagus nerve which is also called the pneumogastric nerve is resected. There are many types
of vagotomy such as:
  Truncal vagotomy First the pylorus is drained and then divides the main trunk of the vagus.
 Selective vagotomy In this procedure too, the pylorus is first drained and then the anterior and
posterior nerves of Latarjet are divided.
 Highly selective vagotomy This is also called proximal gastric vagotomy and involves denervation of
the fundus and body of the stomach.

Endoscopic variceal ligation (EVL) : For patients who present with bleeding from esophageal varices
(swollen veins in the food pipe), endoscopic variceal ligation is the treatment of choice and surgery is usually
done as a last resort if all other measures fail. The procedure is done endoscopically where an enlarged vein or
varix in the esophagus ligated with a rubber band. In view of the poor liver condition these patients are not
good candidates for surgery.
Non-cirrhotics are the ones with portal vein thrombosis or non-cirrhotic portal fibrosis also form a large
component of GI bleeding. These patients do very well after surgery because of their preserved liver condition.
Splenorenal shunt and splenectomy with devascularisation : Some patients presenting with intermittent
vomiting of blood or passing melena will require surgical treatment as a permanent cure for bleeding. Surgery
is either in the form of a spleno-renal shunt in non-cirrhotic patients or splenectomy with devascularisation in
cirrhotic patients.

 Splenorenal shunt : In a splenorenal shunt procedure, the vein from the spleen is detached from the
portal vein and attached to the renal vein, thereby reducing the varices.
 Splenectomy and devascularization : New procedures for splenectomy and devascularization require
that a splenectomy is done first. The distal esophagus is then devascularized through the diaphragm
hiatus.

b.

9. Medical Management- Medications that should be started prior to endoscopy include a proton
pump inhibitor, erythromycin, antibiotics (for patients with cirrhosis), and somatostatin or one
of its analogs (for patients with suspected variceal bleeding).
a. Acid suppression- Proton pump inhibitor (i.e., esomeprazole)
i. High-dose bolus to patients with signs of active bleeding (eg, hematemesis,
hemodynamic instability)
ii. PPIs may also promote hemostasis in patients with lesions other than ulcers.
This likely occurs because neutralization of gastric acid leads to the stabilization
of blood clots
iii. We suggest that patients admitted to the hospital with acute upper GI bleeding
receive an IV proton pump inhibitor (PPI). (Grade 2B). The optimal approach to
 PPI administration prior to endoscopy is unclear. Our approach is to give a high-
dose bolus (eg, esomeprazole 80 mg) to patients with signs of active bleeding
(eg, hematemesis, hemodynamic instability). If endoscopy is delayed beyond 12
hours, a second dose of an IV PPI should be given (eg, esomeprazole 40 mg). For
patients who may have stopped bleeding (eg, patients who are
hemodynamically stable with melena), we give an IV PPI every 12 hours (eg,
esomeprazole 40 mg). Subsequent dosing will then depend on the endoscopic
findings.
b. Prokinetics- Both erythromycin and metoclopramide have been studied in patients with
acute upper GI bleeding.
i. The goal of using a prokinetic agent is to improve gastric visualization at the
time of endoscopy by clearing the stomach of blood, clots, and food residue.
ii. It is suggested by “” that erythromycin be used before endoscopy
iii. Erythromycin promotes gastric emptying based upon its ability to be an agonist
of motilin receptors
iv. We suggest that erythromycin be given prior to endoscopy to help improve
visualization (Grade 2C). A reasonable dose is 250 mg intravenously over 20 to
30 minutes, 30 to 90 minutes prior to endoscopy. Patients receiving
erythromycin need to be monitored for QTc prolongation. In addition, drug-drug
interactions should be evaluated before giving erythromycin because it is a
cytochrome P450 3A inhibitor
v. Prokinetic agent- metoclopromide increases the yield of upper endoscopy and
decreases the need for second look endoscopy
c. Vasoactive medication- treatment of variceal bleeding and may also reduce the risk of
bleeding due to nonvariceal causes
i. Somatostatin, its analog octreotide, and terlipressin (not available in the United
States)
ii. Somatostatin, its analog octreotide, or terlipressin (not available in the United
States) should be started if variceal bleeding is suspected.

d. Antibiotics for patients with cirrhosis- Antibiotics may also reduce the risk of recurrent
bleeding in hospitalized patients who bled from esophageal varices. A reasonable
conclusion from these data is that patients with cirrhosis who present with acute upper
GI bleeding (from varices or other causes) should be given prophylactic antibiotics,
preferably before endoscopy (although effectiveness has also been demonstrated when
given after endoscopy).
i. Patients with cirrhosis who present with acute upper GI bleeding (from varices
or other causes) should be given prophylactic antibiotics.
e. Endoscopy
f. Gastric Lavage

10. Prevention
People with a history of GI bleeds or ulcers can lower their risk of GI bleeding by:
- avoiding alcohol
 - stopping smoking, if a smoker, or avoiding secondhand smoke
i. Smoking and alcohol use impair ulcer healing, and
patients should be counseled about smoking cessation
and moderation of alcohol use.
- limiting or stopping the use of NSAIDs
i. NSAIDs block Cox-1 enzyme, disrupting prostaglandin
production in the stomach
ii. Prostaglandins can have healing effects, especially in
the stomach. They decrease stomach acid production
while also stimulating the release of protective mucus in
the GI tract. In addition, prostaglandins also influence
blood clotting to prevent bleeding. They also help
dissolve clots when a person is healing.
People with GERD may also find that certain dietary changes help alleviate their
symptoms by reducing irritation and inflammation. People can try avoiding:
- caffeine
- minty, spicy, or acidic foods
- high fat foods

Sources:
https://www.mayoclinic.org/diseases-conditions/gastrointestinal-bleeding/symptoms-
causes/syc-20372729
https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-
bleeding-in-adults/print
https://www.medicalnewstoday.com/articles/upper-gi-bleed#risk-factors
Understanding acute upper gastrointestinal bleeding in adult... : Nursing2021 (lww.com)
https://www.thegastrosurgeon.com/gi-bleeding-surgery