Description/Etiology
Upper gastrointestinal (GI) hemorrhage, commonly called upper GI bleeding (UGIB), is a potentially life-threatening emergency characterized by GI bleeding from a source located above the ligament of Treitz (i.e., the suspensory muscle of the duodenum), which connects the duodenum to the diaphragm. There are two types of UGIB: variceal and nonvariceal (for more information, see Quick Lesson About … Gastrointestinal Hemorrhage, Upper Tract: Nonvariceal, and Quick Lesson About … Gastrointestinal Hemorrhage, Upper Tract: Variceal). Variceal hemorrhage is bleeding from esophageal varices (i.e., dilated collateral veins in the lower esophagus that develop due to obstruction of the portal venous system in persons with liver disease; see Quick Lesson About … Esophageal Varices). Nonvariceal UGIB is most commonly caused by peptic ulcer disease. Other causes of nonvariceal UGIB include nonspecific gastric erosions, Mallory-Weiss syndrome, tumors, gastritis, and esophagitis.
UGIB varies in severity and clinical presentation. Patients with acute UGIB may present to the emergency department with hypotension, tachycardia, and hematemesis (i.e., vomiting of blood). In less severe forms, patients may experience mild symptoms related to anemia (e.g., fatigue, nausea, dizziness).
Management of UGIB requires rapid risk assessment to prevent complications, early endoscopic evaluation, endoscopic intervention in high-risk lesions, and appropriate hemostasis. Treatment depends upon the cause and severity of the bleeding. Patients with anemia of unknown origin usually undergo a diagnostic workup to rule out GI bleeding; treatment is specific to the cause. The American College of Gastroenterology guidelines recommend high-dose, continuous infusion therapy with proton pump inhibitors (PPIs) in patients with active bleeding and patients with a high-risk of recurrent bleeding. A nasogastric tube is used to aspirate stomach contents to determine if bleeding is from the upper or lower GI tract. Endoscopy is performed to locate and evaluate the lesionas well as provide treatment. Therapeutic endoscopy may employ one of several techniques to treat the bleeding, including thermal or mechanical means, or injection with a chemical agent. If bleeding does not respond to endoscopic therapy, invasive surgery may be necessary. If the cause of the bleed is not critical (e.g., slow bleeding from a peptic ulcer), the patient can be treated on an outpatient basis with antibiotics or other pharmacologic agents or procedures to control bleeding or eliminate the underlying cause of the bleed. In severe UGIB emergency resuscitation is essential, including I.V. fluids, blood transfusion, oxygen, intensive monitoring, and other supportive measures.
Facts and Figures
Approximately 100,000 to 500,000patients in the United States are hospitalized each year for UGIB. The estimated incidence of UGIB is 100:100,000 patients per year. Peptic ulcer disease accounts for 62% of cases of UGIB, while an estimated 6% of all cases of UGIB are the result of esophageal varices. About 80% of cases of UGIB caused by peptic ulcer disease resolve spontaneously. Mortality rates are 6–10% overall and 12–25% in patients older than 60 years of age. Rebleeding occurs in 10–20% of patients after successful endoscopic therapy.
Risk Factors
Peptic ulcer disease is the major risk factor for UGIB; risk of peptic ulcer disease is increased in individuals infected with the bacterium Helicobacter pylori, as well as in those who use aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) or abuse alcohol. Cirrhosis, which is commonly caused by chronic alcohol abuse and/or hepatitis B or hepatitis C infection, is the primary risk factor for esophageal varices. Risk of variceal bleeding is increased in patients with high portal vein pressure, large varices, red marks on varices, severe cirrhosis or liver failure, fluid buildup, continued alcohol use (in patients with alcohol-related liver disease), and acid reflux. Medications that increase risk for UGIB include anticoagulants (e.g., warfarin), antiplatelet drugs (e.g., clopidogrel), and selective serotonin reuptake inhibitors (SSRIs), especially when used in combination with aspirin or other NSAIDs. Males have a 2-fold greater incidence for UGIB compared to females, but the mortality rate is similar.
Signs and Symptoms/Clinical Presentation
The clinical presentation of acute UGIB may include hematemesis (bloody vomitus), melena (i.e., black, tarry feces, generally associated with bleeding in the upper GI tract), hematochezia (i.e., bloody stools generally associated with bleeding in the lower GI tract), hypotension, and tachycardia. Chronic UGIB may manifest with anemia, nausea, abdominal pain, or dizziness.
Assessment
Patient History
Patient history should include history of symptoms, medication use (including NSAIDs), and alcohol consumption
Physical Findings of Particular Interest
Patients in shock with UGIB have typically lost 20% of their blood volume
Orthostatic changes in blood pressure may be evident in patients who have lost blood
Laboratory Tests That May Be Ordered
Type and cross-match is usually performed for possible blood transfusion
Baseline hemoglobin and hematocrit levels may indicate blood loss and are used to evaluate future blood loss
Prothrombin time (PT) and activated partial thromboplastin time (aPTT) may indicate abnormalities in blood coagulation
Abnormal BUN levels may indicate UGIB
Test for H. pylori infection may be positive
Fecal occult blood test is positive in both acute and chronic GI bleeding
Other Diagnostic Tests/Studies
Upper GI series and endoscopy will indicate the source of GI bleeding
Treatment Goals
Provide Emergency Resuscitation for Hemorrhage and Prevent Complications
Monitor for hypovolemia and shock by frequently checking vital signs for tachycardia and hypotension; assess for restlessness and clammy, pale skin
Administer supplemental oxygen, I.V. fluids, and blood transfusions, as ordered
Administer prescribed pharmacologic agents to reduce portal pressure and control bleeding (e.g., I.V. vasoconstrictor agents; beta blockers)
Administer prescribed antibiotics and a PPIfor patients with peptic ulcers due to H. pylori, and/or with active bleeding or a high-risk of recurrent bleeding; monitor treatment efficacy and for adverse effects
Follow facility pre- and postprocedure/surgical protocols if patient becomes a candidate for endoscopy or surgery
Reinforce pre- and postprocedure/surgical education and verify completion of facility informed consent documents
Following endoscopy or surgery, monitor closely for complications
Assess for orthostatic hypotension and reactions to medication adjustments
Elevate the head of the bed and maintain a cool, quiet environment
Perform frequent positional blood pressure monitoring
Assess fall risk and maintain patient safety (e.g., airway, circulation, and prevention of injury); assess for comorbid conditions and treat, as ordered
Assist with use of elastic stockings; assist with activities of daily living and ambulation, as appropriate
Maintain good oral and overall hygiene, with bed linen changes, as necessary
Support Emotional Well-Being and Educate
Assess anxiety level and coping ability; provide emotional support, educate, and encourage discussion of UGIB pathophysiology, potential complications, treatment risks and benefits, recurrence risk, prevention strategies, lifestyle changes (e.g., alcohol and NSAID avoidance, stress reduction), and individualized prognosis
Request clinician referral, if appropriate, to a
mental health clinician for counseling on coping strategies or stress reduction
social worker for identification of local resources for programs on smoking cessation, Alcoholics Anonymous (AA), support groups, and in-home services
Food for Thought
Critically ill burn patients are at increased risk for UGIB; in a recent retrospective study of 50 burn ICU patients, researchers determined that gastric tube feedings are effective prophylaxis against UGIB and that patients who cannot tolerate tube feedings should receive acid suppression therapy (Yenikomshian et al., 2011)
Investigators found an increased risk for UGIB in a study of 5,377 patients taking SSRIs for 7 to 28 days. The highest level of risk was among patients taking fluoxetine or sertraline and NSAIDs (Wang et al., 2014)
Authors of a Cochrane systematic review report that there is insufficient research evidence to determine the optimal dose and route of administration of PPIs for the treatment of peptic ulcer bleeding. More research is required (Neumann et al., 2013)
Red Flags
Red Flags Endoscopy may compromise cardiovascular function; ventricular arrhythmias and myocardial ischemia, although usually subclinical, are common in patients with coronary artery disease undergoing endoscopy
Red Flags Advanced age is associated with significantly increased risk of mortality in patients with UGIB; the mortality rate ranges from 12-25% in patients > 60 years of age with a UGIB
Red Flags Refusal of blood transfusions due to religious beliefs in patients with massive acute bleeding may complicate treatment
Red Flags Patients receiving large transfusions should be monitored for hypocalcemia and hyperkalemia
Red Flags Risk of GI perforation is 0.5–1% in patients undergoing endoscopy for UGIB
What Do I Need to Tell the Patient/Patient’s Family?
Advise that NSAIDs, alcohol, and smoking should be avoided because they can cause or worsen bleeding ulcers or underlying liver disease
Emphasize the importance of completing the antibiotic treatment regimen prescribed for H. pylori
Discuss the need for continued medical surveillance to monitor for recurrence of UGIB; educate regarding signs and symptoms of UGIB and direct to seek immediate medical attention for new or worsening signs and symptoms
Description/EtiologyUpper gastrointestinal (GI) hemorrhage, commonly called upper GI bleeding (UGIB), is a potentially life-threatening emergency characterized by GI bleeding from a source located above the ligament of Treitz (i.e., the suspensory muscle of the duodenum), which connects the duodenum to the diaphragm. There are two types of UGIB: variceal and nonvariceal (for more information, see Quick Lesson About … Gastrointestinal Hemorrhage, Upper Tract: Nonvariceal, and Quick Lesson About … Gastrointestinal Hemorrhage, Upper Tract: Variceal). Variceal hemorrhage is bleeding from esophageal varices (i.e., dilated collateral veins in the lower esophagus that develop due to obstruction of the portal venous system in persons with liver disease; see Quick Lesson About … Esophageal Varices). Nonvariceal UGIB is most commonly caused by peptic ulcer disease. Other causes of nonvariceal UGIB include nonspecific gastric erosions, Mallory-Weiss syndrome, tumors, gastritis, and esophagitis.UGIB varies in severity and clinical presentation. Patients with acute UGIB may present to the emergency department with hypotension, tachycardia, and hematemesis (i.e., vomiting of blood). In less severe forms, patients may experience mild symptoms related to anemia (e.g., fatigue, nausea, dizziness).Management of UGIB requires rapid risk assessment to prevent complications, early endoscopic evaluation, endoscopic intervention in high-risk lesions, and appropriate hemostasis. Treatment depends upon the cause and severity of the bleeding. Patients with anemia of unknown origin usually undergo a diagnostic workup to rule out GI bleeding; treatment is specific to the cause. The American College of Gastroenterology guidelines recommend high-dose, continuous infusion therapy with proton pump inhibitors (PPIs) in patients with active bleeding and patients with a high-risk of recurrent bleeding. A nasogastric tube is used to aspirate stomach contents to determine if bleeding is from the upper or lower GI tract. Endoscopy is performed to locate and evaluate the lesionas well as provide treatment. Therapeutic endoscopy may employ one of several techniques to treat the bleeding, including thermal or mechanical means, or injection with a chemical agent. If bleeding does not respond to endoscopic therapy, invasive surgery may be necessary. If the cause of the bleed is not critical (e.g., slow bleeding from a peptic ulcer), the patient can be treated on an outpatient basis with antibiotics or other pharmacologic agents or procedures to control bleeding or eliminate the underlying cause of the bleed. In severe UGIB emergency resuscitation is essential, including I.V. fluids, blood transfusion, oxygen, intensive monitoring, and other supportive measures.Facts and FiguresApproximately 100,000 to 500,000patients in the United States are hospitalized each year for UGIB. The estimated incidence of UGIB is 100:100,000 patients per year. Peptic ulcer disease accounts for 62% of cases of UGIB, while an estimated 6% of all cases of UGIB are the result of esophageal varices. About 80% of cases of UGIB caused by peptic ulcer disease resolve spontaneously. Mortality rates are 6–10% overall and 12–25% in patients older than 60 years of age. Rebleeding occurs in 10–20% of patients after successful endoscopic therapy.Risk FactorsPeptic ulcer disease is the major risk factor for UGIB; risk of peptic ulcer disease is increased in individuals infected with the bacterium Helicobacter pylori, as well as in those who use aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) or abuse alcohol. Cirrhosis, which is commonly caused by chronic alcohol abuse and/or hepatitis B or hepatitis C infection, is the primary risk factor for esophageal varices. Risk of variceal bleeding is increased in patients with high portal vein pressure, large varices, red marks on varices, severe cirrhosis or liver failure, fluid buildup, continued alcohol use (in patients with alcohol-related liver disease), and acid reflux. Medications that increase risk for UGIB include anticoagulants (e.g., warfarin), antiplatelet drugs (e.g., clopidogrel), and selective serotonin reuptake inhibitors (SSRIs), especially when used in combination with aspirin or other NSAIDs. Males have a 2-fold greater incidence for UGIB compared to females, but the mortality rate is similar.Signs and Symptoms/Clinical PresentationThe clinical presentation of acute UGIB may include hematemesis (bloody vomitus), melena (i.e., black, tarry feces, generally associated with bleeding in the upper GI tract), hematochezia (i.e., bloody stools generally associated with bleeding in the lower GI tract), hypotension, and tachycardia. Chronic UGIB may manifest with anemia, nausea, abdominal pain, or dizziness.AssessmentPatient HistoryPatient history should include history of symptoms, medication use (including NSAIDs), and alcohol consumptionPhysical Findings of Particular InterestPatients in shock with UGIB have typically lost 20% of their blood volumeOrthostatic changes in blood pressure may be evident in patients who have lost bloodLaboratory Tests That May Be OrderedType and cross-match is usually performed for possible blood transfusionBaseline hemoglobin and hematocrit levels may indicate blood loss and are used to evaluate future blood lossProthrombin time (PT) and activated partial thromboplastin time (aPTT) may indicate abnormalities in blood coagulationAbnormal BUN levels may indicate UGIBTest for H. pylori infection may be positiveFecal occult blood test is positive in both acute and chronic GI bleedingOther Diagnostic Tests/StudiesUpper GI series and endoscopy will indicate the source of GI bleedingTreatment GoalsProvide Emergency Resuscitation for Hemorrhage and Prevent ComplicationsMonitor for hypovolemia and shock by frequently checking vital signs for tachycardia and hypotension; assess for restlessness and clammy, pale skinAdminister supplemental oxygen, I.V. fluids, and blood transfusions, as orderedAdminister prescribed pharmacologic agents to reduce portal pressure and control bleeding (e.g., I.V. vasoconstrictor agents; beta blockers)Administer prescribed antibiotics and a PPIfor patients with peptic ulcers due to H. pylori, and/or with active bleeding or a high-risk of recurrent bleeding; monitor treatment efficacy and for adverse effectsFollow facility pre- and postprocedure/surgical protocols if patient becomes a candidate for endoscopy or surgery
Reinforce pre- and postprocedure/surgical education and verify completion of facility informed consent documents
Following endoscopy or surgery, monitor closely for complications
Assess for orthostatic hypotension and reactions to medication adjustments
Elevate the head of the bed and maintain a cool, quiet environment
Perform frequent positional blood pressure monitoring
Assess fall risk and maintain patient safety (e.g., airway, circulation, and prevention of injury); assess for comorbid conditions and treat, as ordered
Assist with use of elastic stockings; assist with activities of daily living and ambulation, as appropriate
Maintain good oral and overall hygiene, with bed linen changes, as necessary
Support Emotional Well-Being and Educate
Assess anxiety level and coping ability; provide emotional support, educate, and encourage discussion of UGIB pathophysiology, potential complications, treatment risks and benefits, recurrence risk, prevention strategies, lifestyle changes (e.g., alcohol and NSAID avoidance, stress reduction), and individualized prognosis
Request clinician referral, if appropriate, to a
mental health clinician for counseling on coping strategies or stress reduction
social worker for identification of local resources for programs on smoking cessation, Alcoholics Anonymous (AA), support groups, and in-home services
Food for Thought
Critically ill burn patients are at increased risk for UGIB; in a recent retrospective study of 50 burn ICU patients, researchers determined that gastric tube feedings are effective prophylaxis against UGIB and that patients who cannot tolerate tube feedings should receive acid suppression therapy (Yenikomshian et al., 2011)
Investigators found an increased risk for UGIB in a study of 5,377 patients taking SSRIs for 7 to 28 days. The highest level of risk was among patients taking fluoxetine or sertraline and NSAIDs (Wang et al., 2014)
Authors of a Cochrane systematic review report that there is insufficient research evidence to determine the optimal dose and route of administration of PPIs for the treatment of peptic ulcer bleeding. More research is required (Neumann et al., 2013)
Red Flags
Red Flags Endoscopy may compromise cardiovascular function; ventricular arrhythmias and myocardial ischemia, although usually subclinical, are common in patients with coronary artery disease undergoing endoscopy
Red Flags Advanced age is associated with significantly increased risk of mortality in patients with UGIB; the mortality rate ranges from 12-25% in patients > 60 years of age with a UGIB
Red Flags Refusal of blood transfusions due to religious beliefs in patients with massive acute bleeding may complicate treatment
Red Flags Patients receiving large transfusions should be monitored for hypocalcemia and hyperkalemia
Red Flags Risk of GI perforation is 0.5–1% in patients undergoing endoscopy for UGIB
What Do I Need to Tell the Patient/Patient’s Family?
Advise that NSAIDs, alcohol, and smoking should be avoided because they can cause or worsen bleeding ulcers or underlying liver disease
Emphasize the importance of completing the antibiotic treatment regimen prescribed for H. pylori
Discuss the need for continued medical surveillance to monitor for recurrence of UGIB; educate regarding signs and symptoms of UGIB and direct to seek immediate medical attention for new or worsening signs and symptoms
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