Upper gastrointestinal bleeding history and symptoms: Difference between revisions
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==Overview== | ==Overview== | ||
Patients with upper GI hemorrhage often present with [[hematemesis]], [[coffee ground vomiting]], [[melena]], maroon stool, or [[hematochezia]] if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage. Patients may also present with complications of [[anemia]], including chest pain, [[syncope]], [[fatigue (physical)|fatigue]] and shortness of breath. | Patients with upper [[Gastrointestinal tract|GI]] [[hemorrhage]] often present with [[hematemesis]], [[coffee ground vomiting]], [[melena]], maroon [[stool]], or [[hematochezia]] if the [[hemorrhage]] is severe. The presentation of [[bleeding]] depends on the amount and location of [[hemorrhage]]. Patients may also present with [[complications]] of [[anemia]], including [[chest pain]], [[syncope]], [[fatigue (physical)|fatigue]] and [[shortness of breath]]. Obtaining the history is the most important aspect of making a [[diagnosis]] of upper [[Gastrointestinal tract|GI]] [[bleed]]. It provides insight into the [[Causality|cause]], precipitating factors and associated [[comorbid]] conditions and also helps in determining the severity of the [[bleed]] as well as in identifying the potential source of [[bleed]]. | ||
==History== | ==History== | ||
Obtaining the history is the most important aspect of making a diagnosis of upper GI bleed. It provides insight into the cause, precipitating factors and associated comorbid conditions and also helps in determining the severity of the bleed as well as in identifying the potential source of bleed | Obtaining the history is the most important aspect of making a [[diagnosis]] of upper [[Gastrointestinal tract|GI]] [[bleed]]. It provides insight into the [[Causality|cause]], precipitating factors and associated [[comorbid]] conditions and also helps in determining the severity of the [[bleed]] as well as in identifying the [[potential]] source of [[bleed]]. Patients may be [[Disorientation|disoriented]], therefore, the patient interview may be difficult. In such cases, history from the care givers or the family members may need to be obtained. <ref name="pmid25400991">{{cite journal |vauthors=Kim BS, Li BT, Engel A, Samra JS, Clarke S, Norton ID, Li AE |title=Diagnosis of gastrointestinal bleeding: A practical guide for clinicians |journal=World J Gastrointest Pathophysiol |volume=5 |issue=4 |pages=467–78 |year=2014 |pmid=25400991 |pmc=4231512 |doi=10.4291/wjgp.v5.i4.467 |url=}}</ref><ref name="pmid23547576">{{cite journal |vauthors=Bull-Henry K, Al-Kawas FH |title=Evaluation of occult gastrointestinal bleeding |journal=Am Fam Physician |volume=87 |issue=6 |pages=430–6 |year=2013 |pmid=23547576 |doi= |url=}}</ref> | ||
===Past Medical History=== | ===Past Medical History=== | ||
*A history of epigastric pain, dyspepsia, or prior peptic ulcer may suggest the diagnosis of peptic ulcer disease.<ref name="LaineSolomon2016">{{cite journal|last1=Laine|first1=Loren|last2=Solomon|first2=Caren G.|title=Upper Gastrointestinal Bleeding Due to a Peptic Ulcer|journal=New England Journal of Medicine|volume=374|issue=24|year=2016|pages=2367–2376|issn=0028-4793|doi=10.1056/NEJMcp1514257}}</ref> | *A history of [[epigastric pain]], [[dyspepsia]], or prior [[peptic ulcer]] may suggest the [[Diagnosis-related group|diagnosis]] of [[peptic ulcer disease]].<ref name="LaineSolomon2016">{{cite journal|last1=Laine|first1=Loren|last2=Solomon|first2=Caren G.|title=Upper Gastrointestinal Bleeding Due to a Peptic Ulcer|journal=New England Journal of Medicine|volume=374|issue=24|year=2016|pages=2367–2376|issn=0028-4793|doi=10.1056/NEJMcp1514257}}</ref> | ||
*A history of documented prior upper GI bleeding is important because approximately 60% of upper GI bleeders are rebleeding from the same site. | *A history of documented prior upper [[Gastrointestinal tract|GI]] [[bleeding]] is important because approximately 60% of upper [[Gastrointestinal tract|GI]] bleeders are rebleeding from the same site. | ||
*A history of pancreatitis suggests possible hemorrhage from a pancreatic pseudocyst. Erosion of a pancreatic pseudocyst into the duodenum or stomach may cause massive hematemesis, and the patient may present in shock.<ref name="pmid16955152">{{cite journal |vauthors=Stermer E, Elias N, Keren D, Rainis T, Goldstein O, Lavy A |title=Acute pancreatitis and upper gastrointestinal bleeding as presenting symptoms of duodenal Brunner's gland hamartoma |journal=Can. J. Gastroenterol. |volume=20 |issue=8 |pages=541–2 |year=2006 |pmid=16955152 |pmc=2659938 |doi= |url=}}</ref><ref name="pmid26591952">{{cite journal |vauthors=Rana SS, Sharma V, Bhasin DK, Sharma R, Gupta R, Chhabra P, Kang M |title=Gastrointestinal bleeding in acute pancreatitis: etiology, clinical features, risk factors and outcome |journal=Trop Gastroenterol |volume=36 |issue=1 |pages=31–5 |year=2015 |pmid=26591952 |doi= |url=}}</ref><ref name="pmid18376304">{{cite journal |vauthors=Sharma PK, Madan K, Garg PK |title=Hemorrhage in acute pancreatitis: should gastrointestinal bleeding be considered an organ failure? |journal=Pancreas |volume=36 |issue=2 |pages=141–5 |year=2008 |pmid=18376304 |doi=10.1097/MPA.0b013e318158466e |url=}}</ref> | *A history of [[pancreatitis]] suggests possible [[hemorrhage]] from a [[pancreatic pseudocyst]]. Erosion of a [[pancreatic pseudocyst]] into the [[duodenum]] or [[stomach]] may cause massive [[hematemesis]], and the patient may present in [[shock]].<ref name="pmid16955152">{{cite journal |vauthors=Stermer E, Elias N, Keren D, Rainis T, Goldstein O, Lavy A |title=Acute pancreatitis and upper gastrointestinal bleeding as presenting symptoms of duodenal Brunner's gland hamartoma |journal=Can. J. Gastroenterol. |volume=20 |issue=8 |pages=541–2 |year=2006 |pmid=16955152 |pmc=2659938 |doi= |url=}}</ref><ref name="pmid26591952">{{cite journal |vauthors=Rana SS, Sharma V, Bhasin DK, Sharma R, Gupta R, Chhabra P, Kang M |title=Gastrointestinal bleeding in acute pancreatitis: etiology, clinical features, risk factors and outcome |journal=Trop Gastroenterol |volume=36 |issue=1 |pages=31–5 |year=2015 |pmid=26591952 |doi= |url=}}</ref><ref name="pmid18376304">{{cite journal |vauthors=Sharma PK, Madan K, Garg PK |title=Hemorrhage in acute pancreatitis: should gastrointestinal bleeding be considered an organ failure? |journal=Pancreas |volume=36 |issue=2 |pages=141–5 |year=2008 |pmid=18376304 |doi=10.1097/MPA.0b013e318158466e |url=}}</ref> | ||
*Patients with renal failure frequently have GI bleeding. This bleeding is often due to peptic ulcer disease or angiodysplasia. This bleeding may be severe because of clotting dysfunction associated with renal disease.<ref name="pmid8931412">{{cite journal |vauthors=Chalasani N, Cotsonis G, Wilcox CM |title=Upper gastrointestinal bleeding in patients with chronic renal failure: role of vascular ectasia |journal=Am. J. Gastroenterol. |volume=91 |issue=11 |pages=2329–32 |year=1996 |pmid=8931412 |doi= |url=}}</ref><ref name="pmid3872616">{{cite journal |vauthors=Zuckerman GR, Cornette GL, Clouse RE, Harter HR |title=Upper gastrointestinal bleeding in patients with chronic renal failure |journal=Ann. Intern. Med. |volume=102 |issue=5 |pages=588–92 |year=1985 |pmid=3872616 |doi= |url=}}</ref> | *Patients with [[renal failure]] frequently have [[Gastrointestinal tract|GI]] [[bleeding]]. This bleeding is often due to [[peptic ulcer disease]] or [[angiodysplasia]]. This [[bleeding]] may be severe because of [[clotting]] [[dysfunction]] associated with [[renal disease]].<ref name="pmid8931412">{{cite journal |vauthors=Chalasani N, Cotsonis G, Wilcox CM |title=Upper gastrointestinal bleeding in patients with chronic renal failure: role of vascular ectasia |journal=Am. J. Gastroenterol. |volume=91 |issue=11 |pages=2329–32 |year=1996 |pmid=8931412 |doi= |url=}}</ref><ref name="pmid3872616">{{cite journal |vauthors=Zuckerman GR, Cornette GL, Clouse RE, Harter HR |title=Upper gastrointestinal bleeding in patients with chronic renal failure |journal=Ann. Intern. Med. |volume=102 |issue=5 |pages=588–92 |year=1985 |pmid=3872616 |doi= |url=}}</ref> | ||
===Medication History=== | ===Medication History=== | ||
*Prior use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) is important because these patients have an increased risk of gastric ulcer and a fourfold risk of significant GI bleeding compared with other patients.<ref name="pmid5303551">{{cite journal |vauthors=Goulston K, Cooke AR |title=Alcohol, aspirin, and gastrointestinal bleeding |journal=Br Med J |volume=4 |issue=5632 |pages=664–5 |year=1968 |pmid=5303551 |pmc=1912769 |doi= |url=}}</ref> | *Prior use of [[aspirin]] or [[Non-steroidal anti-inflammatory drug|nonsteroidal anti-inflammatory drugs]] (NSAIDs) is important because these patients have an increased risk of [[gastric ulcer]] and a fourfold risk of significant [[Gastrointestinal tract|GI]] [[bleeding]] compared with other patients.<ref name="pmid5303551">{{cite journal |vauthors=Goulston K, Cooke AR |title=Alcohol, aspirin, and gastrointestinal bleeding |journal=Br Med J |volume=4 |issue=5632 |pages=664–5 |year=1968 |pmid=5303551 |pmc=1912769 |doi= |url=}}</ref> | ||
===Social History=== | ===Social History=== | ||
*A history of alcoholism increases the likelihood of cirrhosis and consequently of bleeding from esophageal varices or congestive gastropathy but alcoholics also frequently have peptic ulcers or gastritis.<ref name="pmid2226291">{{cite journal |vauthors=MacMath TL |title=Alcohol and gastrointestinal bleeding |journal=Emerg. Med. Clin. North Am. |volume=8 |issue=4 |pages=859–72 |year=1990 |pmid=2226291 |doi= |url=}}</ref><ref name="pmid5303551">{{cite journal |vauthors=Goulston K, Cooke AR |title=Alcohol, aspirin, and gastrointestinal bleeding |journal=Br Med J |volume=4 |issue=5632 |pages=664–5 |year=1968 |pmid=5303551 |pmc=1912769 |doi= |url=}}</ref> | *A history of [[alcoholism]] increases the likelihood of [[cirrhosis]] and consequently of [[bleeding]] from [[esophageal varices]] or congestive gastropathy but alcoholics also frequently have [[peptic ulcers]] or [[gastritis]].<ref name="pmid2226291">{{cite journal |vauthors=MacMath TL |title=Alcohol and gastrointestinal bleeding |journal=Emerg. Med. Clin. North Am. |volume=8 |issue=4 |pages=859–72 |year=1990 |pmid=2226291 |doi= |url=}}</ref><ref name="pmid5303551">{{cite journal |vauthors=Goulston K, Cooke AR |title=Alcohol, aspirin, and gastrointestinal bleeding |journal=Br Med J |volume=4 |issue=5632 |pages=664–5 |year=1968 |pmid=5303551 |pmc=1912769 |doi= |url=}}</ref> | ||
*Cigarette smokers have a significantly higher rate of the recurrent duodenal ulcer as compared with nonsmokers and a history of cigarette smoking should be elicited. | *[[Cigarette smoke|Cigarette smokers]] have a significantly higher rate of the recurrent [[duodenal ulcer]] as compared with nonsmokers and a history of [[cigarette smoking]] should be elicited. | ||
*Vomiting, coughing, or retching before bleeding is suggestive of a Mallory-Weiss tear.<ref name="pmid28839832">{{cite journal |vauthors=Jafar W, Jafar AJN, Sharma A |title=Upper gastrointestinal haemorrhage: an update |journal=Frontline Gastroenterol |volume=7 |issue=1 |pages=32–40 |year=2016 |pmid=28839832 |pmc=5369541 |doi=10.1136/flgastro-2014-100492 |url=}}</ref><ref name="pmid17942452">{{cite journal |vauthors=Palmer K |title=Acute upper gastrointestinal haemorrhage |journal=Br. Med. Bull. |volume=83 |issue= |pages=307–24 |year=2007 |pmid=17942452 |doi=10.1093/bmb/ldm023 |url=}}</ref> | *[[Vomiting]], [[coughing]], or [[retching]] before [[bleeding]] is suggestive of a [[Mallory-Weiss tear]].<ref name="pmid28839832">{{cite journal |vauthors=Jafar W, Jafar AJN, Sharma A |title=Upper gastrointestinal haemorrhage: an update |journal=Frontline Gastroenterol |volume=7 |issue=1 |pages=32–40 |year=2016 |pmid=28839832 |pmc=5369541 |doi=10.1136/flgastro-2014-100492 |url=}}</ref><ref name="pmid17942452">{{cite journal |vauthors=Palmer K |title=Acute upper gastrointestinal haemorrhage |journal=Br. Med. Bull. |volume=83 |issue= |pages=307–24 |year=2007 |pmid=17942452 |doi=10.1093/bmb/ldm023 |url=}}</ref> | ||
===Past Surgical History=== | ===Past Surgical History=== | ||
*Patients with prior abdominal aortic aneurysm repair may present with severe GI hemorrhage from an aortoenteric. This fistula often presents with a herald bleed followed within 4 to 96 hours by massive bleeding.<ref name="pmid25136194">{{cite journal |vauthors=Adarsh CK, Kiran R, Mallikarjun |title=An unusual cause of gastrointestinal bleed |journal=Indian J Crit Care Med |volume=18 |issue=8 |pages=533–5 |year=2014 |pmid=25136194 |pmc=4134629 |doi=10.4103/0972-5229.138160 |url=}}</ref> | *Patients with prior [[abdominal aortic aneurysm]] repair may present with severe GI [[hemorrhage]] from an aortoenteric. This [[fistula]] often presents with a herald bleed followed within 4 to 96 hours by [[massive bleeding]].<ref name="pmid25136194">{{cite journal |vauthors=Adarsh CK, Kiran R, Mallikarjun |title=An unusual cause of gastrointestinal bleed |journal=Indian J Crit Care Med |volume=18 |issue=8 |pages=533–5 |year=2014 |pmid=25136194 |pmc=4134629 |doi=10.4103/0972-5229.138160 |url=}}</ref> | ||
===Family History=== | ===Family History=== | ||
*A personal or family history of recurrent epistaxis may suggest the diagnosis of Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia), and a careful examination for skin telangiectasias should be performed. <ref name="pmid28070235">{{cite journal |vauthors=Ou G, Galorport C, Enns R |title=Bevacizumab and gastrointestinal bleeding in hereditary hemorrhagic telangiectasia |journal=World J Gastrointest Surg |volume=8 |issue=12 |pages=792–795 |year=2016 |pmid=28070235 |pmc=5183923 |doi=10.4240/wjgs.v8.i12.792 |url=}}</ref> | *A personal or [[family history]] of recurrent [[epistaxis]] may suggest the [[diagnosis]] of [[Osler-Weber-Rendu syndrome]] ([[hereditary hemorrhagic telangiectasia]]), and a careful examination for skin [[telangiectasias]] should be performed. <ref name="pmid28070235">{{cite journal |vauthors=Ou G, Galorport C, Enns R |title=Bevacizumab and gastrointestinal bleeding in hereditary hemorrhagic telangiectasia |journal=World J Gastrointest Surg |volume=8 |issue=12 |pages=792–795 |year=2016 |pmid=28070235 |pmc=5183923 |doi=10.4240/wjgs.v8.i12.792 |url=}}</ref> | ||
==Symptoms== | ==Symptoms== | ||
*Upper GI bleeding occurs proximal to the ligament of Treitz.<ref name="pmid20871188">{{cite journal |vauthors=Kaviani MJ, Pirastehfar M, Azari A, Saberifiroozi M |title=Etiology and outcome of patients with upper gastrointestinal bleeding: a study from South of Iran |journal=Saudi J Gastroenterol |volume=16 |issue=4 |pages=253–9 |year=2010 |pmid=20871188 |pmc=2995092 |doi=10.4103/1319-3767.70608 |url=}}</ref> | *Upper [[Gastrointestinal tract|GI]] [[bleeding]] occurs proximal to the [[ligament of Treitz]].<ref name="pmid20871188">{{cite journal |vauthors=Kaviani MJ, Pirastehfar M, Azari A, Saberifiroozi M |title=Etiology and outcome of patients with upper gastrointestinal bleeding: a study from South of Iran |journal=Saudi J Gastroenterol |volume=16 |issue=4 |pages=253–9 |year=2010 |pmid=20871188 |pmc=2995092 |doi=10.4103/1319-3767.70608 |url=}}</ref> | ||
*Patients with upper GI bleeding usually present with hematemesis or melena.<ref name="pmid27305194">{{cite journal |vauthors=Laine L |title=CLINICAL PRACTICE. Upper Gastrointestinal Bleeding Due to a Peptic Ulcer |journal=N. Engl. J. Med. |volume=374 |issue=24 |pages=2367–76 |year=2016 |pmid=27305194 |doi=10.1056/NEJMcp1514257 |url=}}</ref> | *Patients with upper [[Gastrointestinal tract|GI]] [[bleeding]] usually present with [[hematemesis]] or [[melena]].<ref name="pmid27305194">{{cite journal |vauthors=Laine L |title=CLINICAL PRACTICE. Upper Gastrointestinal Bleeding Due to a Peptic Ulcer |journal=N. Engl. J. Med. |volume=374 |issue=24 |pages=2367–76 |year=2016 |pmid=27305194 |doi=10.1056/NEJMcp1514257 |url=}}</ref> | ||
*In large series, about 50% of patients have hematemesis and melena, about 30% have hematemesis alone, and about 20% have only melena.<ref name="pmid20473658">{{cite journal |vauthors=Grimaldi-Bensouda L, Abenhaim L, Michaud L, Mouterde O, Jonville-Béra AP, Giraudeau B, David B, Autret-Leca E |title=Clinical features and risk factors for upper gastrointestinal bleeding in children: a case-crossover study |journal=Eur. J. Clin. Pharmacol. |volume=66 |issue=8 |pages=831–7 |year=2010 |pmid=20473658 |doi=10.1007/s00228-010-0832-3 |url=}}</ref> | *In large series, about 50% of patients have [[hematemesis]] and [[melena]], about 30% have [[hematemesis]] alone, and about 20% have only [[melena]].<ref name="pmid20473658">{{cite journal |vauthors=Grimaldi-Bensouda L, Abenhaim L, Michaud L, Mouterde O, Jonville-Béra AP, Giraudeau B, David B, Autret-Leca E |title=Clinical features and risk factors for upper gastrointestinal bleeding in children: a case-crossover study |journal=Eur. J. Clin. Pharmacol. |volume=66 |issue=8 |pages=831–7 |year=2010 |pmid=20473658 |doi=10.1007/s00228-010-0832-3 |url=}}</ref> | ||
*On occasion, however, hematochezia may be the only manifestation of a bleeding ulcer, and about 15% of all patients who present with hematochezia have an upper GI source. *Peptic ulcer disease is the most common cause of acute upper GI hemorrhage, accounting for about 40% of cases. | *On occasion, however, [[hematochezia]] may be the only manifestation of a [[Ulcer|bleeding ulcer]], and about 15% of all patients who present with [[hematochezia]] have an upper GI source. | ||
*Other common causes are esophageal and gastric varices and erosive esophagitis, variceal bleeding, which occurs in the setting of portal hypertension. | *[[Peptic ulcer disease]] is the most common cause of acute upper [[Gastrointestinal tract|GI]] [[hemorrhage]], accounting for about 40% of cases. | ||
*Other conditions, such as Mallory-Weiss tears, angiodysplasia, watermelon stomach, tumors, and Dieulafoy lesion, occur less frequently than peptic ulcer. | *Other common causes are [[Esophageal varices|esophageal]] and [[gastric varices]] and [[Esophagitis|erosive esophagitis]], [[variceal bleeding]], which occurs in the setting of [[Portal hypertension|portal hypertension.]] | ||
*The mortality from nonulcer bleeding is comparable to that from ulcer hemorrhage in high-risk patients, so all causes of upper GI hemorrhage contribute to the morbidity and cost of care associated with it.<ref name="pmid19633787">{{cite journal |vauthors=Gundling F, Harms RT, Schiefke I, Schepp W, Mössner J, Teich N |title=Self assessment of warning symptoms in upper gastrointestinal bleeding |journal=Dtsch Arztebl Int |volume=105 |issue=5 |pages=73–7 |year=2008 |pmid=19633787 |pmc=2701246 |doi=10.3238/arztebl.2008.0073 |url=}}</ref> | *Other conditions, such as [[Mallory-Weiss tear|Mallory-Weiss tears]], [[angiodysplasia]], [[watermelon stomach]], [[tumors]], and Dieulafoy lesion, occur less frequently than [[peptic ulcer]]. | ||
*The mortality from nonulcer bleeding is comparable to that from ulcer [[hemorrhage]] in high-risk patients, so all causes of upper GI [[hemorrhage]] contribute to the [[morbidity]] and cost of care associated with it.<ref name="pmid19633787">{{cite journal |vauthors=Gundling F, Harms RT, Schiefke I, Schepp W, Mössner J, Teich N |title=Self assessment of warning symptoms in upper gastrointestinal bleeding |journal=Dtsch Arztebl Int |volume=105 |issue=5 |pages=73–7 |year=2008 |pmid=19633787 |pmc=2701246 |doi=10.3238/arztebl.2008.0073 |url=}}</ref> | |||
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable" | {| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable" | ||
| Line 40: | Line 42: | ||
|Acute upper GI bleeding | |Acute upper GI bleeding | ||
| | | | ||
* Hematemesis | * [[Hematemesis]] | ||
* Melena | * [[Melena]] | ||
* Hematochezia | * [[Hematochezia]] | ||
* Syncope | * [[Syncope]] | ||
* Dyspepsia | * [[Dyspepsia]] | ||
* Epigastric pain | * [[Epigastric pain]] | ||
* Diffuse abdominal pain | * [[Abdominal pain|Diffuse abdominal pain]] | ||
* Dysphagia | * [[Dysphagia]] | ||
* Jaundice | * [[Jaundice]] | ||
|- | |- | ||
|Chronic upper GI bleeding | |Chronic upper GI bleeding | ||
| | | | ||
* Fatigue | * [[Fatigue]] | ||
* Weight loss | * [[Weight loss]] | ||
* Heartburn | * [[Heartburn]] | ||
* Presyncope | * [[Presyncope]] | ||
* [[Indigestion]] | * [[Indigestion]] | ||
* [[Bloating]] | * [[Bloating]] | ||
|} | |} | ||
===Definitions=== | |||
*'''Hematemesis''': [[vomiting]] fresh [[Blood|red blood]]. | |||
*'''Coffee ground emesis''': [[vomiting]] of altered [[Blood|black blood]]. | |||
*'''Melena''': passage of black tarry stools. | |||
*'''Hematochezia''': Passage of red blood per rectum (usually due to bleeding from the [[lower gastrointestinal tract]] but occasionally can be due to massive [[Upper gastrointestinal bleeding|upper gastrointestinal bleeding)]]. | |||
*'''Rebleeding''': Defined as fresh [[haematemesis]] or [[melaena]] associated with the development of [[shock]] (pulse greater than 100 beats/min, [[Systolic blood pressure|systolic pressure]] less than 100 mm Hg), a fall in [[Central venous pressure|CVP]] greater than 5 mm Hg, or a reduction in [[haemoglobin]] concentration greater than 20 g/l over 24 hours. Rebleeding should always be confirmed by [[endoscopy]] | |||
==References== | ==References== | ||
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{{WikiDoc Sources}} | {{WikiDoc Sources}} | ||
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Latest revision as of 16:47, 27 November 2017
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Upper gastrointestinal bleeding Microchapters |
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Differentiating Upper Gastrointestinal Bleeding from other Diseases |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, maroon stool, or hematochezia if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage. Patients may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath. Obtaining the history is the most important aspect of making a diagnosis of upper GI bleed. It provides insight into the cause, precipitating factors and associated comorbid conditions and also helps in determining the severity of the bleed as well as in identifying the potential source of bleed.
History
Obtaining the history is the most important aspect of making a diagnosis of upper GI bleed. It provides insight into the cause, precipitating factors and associated comorbid conditions and also helps in determining the severity of the bleed as well as in identifying the potential source of bleed. Patients may be disoriented, therefore, the patient interview may be difficult. In such cases, history from the care givers or the family members may need to be obtained. [1][2]
Past Medical History
- A history of epigastric pain, dyspepsia, or prior peptic ulcer may suggest the diagnosis of peptic ulcer disease.[3]
- A history of documented prior upper GI bleeding is important because approximately 60% of upper GI bleeders are rebleeding from the same site.
- A history of pancreatitis suggests possible hemorrhage from a pancreatic pseudocyst. Erosion of a pancreatic pseudocyst into the duodenum or stomach may cause massive hematemesis, and the patient may present in shock.[4][5][6]
- Patients with renal failure frequently have GI bleeding. This bleeding is often due to peptic ulcer disease or angiodysplasia. This bleeding may be severe because of clotting dysfunction associated with renal disease.[7][8]
Medication History
- Prior use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) is important because these patients have an increased risk of gastric ulcer and a fourfold risk of significant GI bleeding compared with other patients.[9]
Social History
- A history of alcoholism increases the likelihood of cirrhosis and consequently of bleeding from esophageal varices or congestive gastropathy but alcoholics also frequently have peptic ulcers or gastritis.[10][9]
- Cigarette smokers have a significantly higher rate of the recurrent duodenal ulcer as compared with nonsmokers and a history of cigarette smoking should be elicited.
- Vomiting, coughing, or retching before bleeding is suggestive of a Mallory-Weiss tear.[11][12]
Past Surgical History
- Patients with prior abdominal aortic aneurysm repair may present with severe GI hemorrhage from an aortoenteric. This fistula often presents with a herald bleed followed within 4 to 96 hours by massive bleeding.[13]
Family History
- A personal or family history of recurrent epistaxis may suggest the diagnosis of Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia), and a careful examination for skin telangiectasias should be performed. [14]
Symptoms
- Upper GI bleeding occurs proximal to the ligament of Treitz.[15]
- Patients with upper GI bleeding usually present with hematemesis or melena.[16]
- In large series, about 50% of patients have hematemesis and melena, about 30% have hematemesis alone, and about 20% have only melena.[17]
- On occasion, however, hematochezia may be the only manifestation of a bleeding ulcer, and about 15% of all patients who present with hematochezia have an upper GI source.
- Peptic ulcer disease is the most common cause of acute upper GI hemorrhage, accounting for about 40% of cases.
- Other common causes are esophageal and gastric varices and erosive esophagitis, variceal bleeding, which occurs in the setting of portal hypertension.
- Other conditions, such as Mallory-Weiss tears, angiodysplasia, watermelon stomach, tumors, and Dieulafoy lesion, occur less frequently than peptic ulcer.
- The mortality from nonulcer bleeding is comparable to that from ulcer hemorrhage in high-risk patients, so all causes of upper GI hemorrhage contribute to the morbidity and cost of care associated with it.[18]
| Clinical manifestations | |
|---|---|
| Acute upper GI bleeding | |
| Chronic upper GI bleeding | |
Definitions
- Hematemesis: vomiting fresh red blood.
- Coffee ground emesis: vomiting of altered black blood.
- Melena: passage of black tarry stools.
- Hematochezia: Passage of red blood per rectum (usually due to bleeding from the lower gastrointestinal tract but occasionally can be due to massive upper gastrointestinal bleeding).
- Rebleeding: Defined as fresh haematemesis or melaena associated with the development of shock (pulse greater than 100 beats/min, systolic pressure less than 100 mm Hg), a fall in CVP greater than 5 mm Hg, or a reduction in haemoglobin concentration greater than 20 g/l over 24 hours. Rebleeding should always be confirmed by endoscopy
References
- ↑ Kim BS, Li BT, Engel A, Samra JS, Clarke S, Norton ID, Li AE (2014). "Diagnosis of gastrointestinal bleeding: A practical guide for clinicians". World J Gastrointest Pathophysiol. 5 (4): 467–78. doi:10.4291/wjgp.v5.i4.467. PMC 4231512. PMID 25400991.
- ↑ Bull-Henry K, Al-Kawas FH (2013). "Evaluation of occult gastrointestinal bleeding". Am Fam Physician. 87 (6): 430–6. PMID 23547576.
- ↑ Laine, Loren; Solomon, Caren G. (2016). "Upper Gastrointestinal Bleeding Due to a Peptic Ulcer". New England Journal of Medicine. 374 (24): 2367–2376. doi:10.1056/NEJMcp1514257. ISSN 0028-4793.
- ↑ Stermer E, Elias N, Keren D, Rainis T, Goldstein O, Lavy A (2006). "Acute pancreatitis and upper gastrointestinal bleeding as presenting symptoms of duodenal Brunner's gland hamartoma". Can. J. Gastroenterol. 20 (8): 541–2. PMC 2659938. PMID 16955152.
- ↑ Rana SS, Sharma V, Bhasin DK, Sharma R, Gupta R, Chhabra P, Kang M (2015). "Gastrointestinal bleeding in acute pancreatitis: etiology, clinical features, risk factors and outcome". Trop Gastroenterol. 36 (1): 31–5. PMID 26591952.
- ↑ Sharma PK, Madan K, Garg PK (2008). "Hemorrhage in acute pancreatitis: should gastrointestinal bleeding be considered an organ failure?". Pancreas. 36 (2): 141–5. doi:10.1097/MPA.0b013e318158466e. PMID 18376304.
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- ↑ 9.0 9.1 Goulston K, Cooke AR (1968). "Alcohol, aspirin, and gastrointestinal bleeding". Br Med J. 4 (5632): 664–5. PMC 1912769. PMID 5303551.
- ↑ MacMath TL (1990). "Alcohol and gastrointestinal bleeding". Emerg. Med. Clin. North Am. 8 (4): 859–72. PMID 2226291.
- ↑ Jafar W, Jafar A, Sharma A (2016). "Upper gastrointestinal haemorrhage: an update". Frontline Gastroenterol. 7 (1): 32–40. doi:10.1136/flgastro-2014-100492. PMC 5369541. PMID 28839832. Vancouver style error: initials (help)
- ↑ Palmer K (2007). "Acute upper gastrointestinal haemorrhage". Br. Med. Bull. 83: 307–24. doi:10.1093/bmb/ldm023. PMID 17942452.
- ↑ Adarsh CK, Kiran R, Mallikarjun (2014). "An unusual cause of gastrointestinal bleed". Indian J Crit Care Med. 18 (8): 533–5. doi:10.4103/0972-5229.138160. PMC 4134629. PMID 25136194.
- ↑ Ou G, Galorport C, Enns R (2016). "Bevacizumab and gastrointestinal bleeding in hereditary hemorrhagic telangiectasia". World J Gastrointest Surg. 8 (12): 792–795. doi:10.4240/wjgs.v8.i12.792. PMC 5183923. PMID 28070235.
- ↑ Kaviani MJ, Pirastehfar M, Azari A, Saberifiroozi M (2010). "Etiology and outcome of patients with upper gastrointestinal bleeding: a study from South of Iran". Saudi J Gastroenterol. 16 (4): 253–9. doi:10.4103/1319-3767.70608. PMC 2995092. PMID 20871188.
- ↑ Laine L (2016). "CLINICAL PRACTICE. Upper Gastrointestinal Bleeding Due to a Peptic Ulcer". N. Engl. J. Med. 374 (24): 2367–76. doi:10.1056/NEJMcp1514257. PMID 27305194.
- ↑ Grimaldi-Bensouda L, Abenhaim L, Michaud L, Mouterde O, Jonville-Béra AP, Giraudeau B, David B, Autret-Leca E (2010). "Clinical features and risk factors for upper gastrointestinal bleeding in children: a case-crossover study". Eur. J. Clin. Pharmacol. 66 (8): 831–7. doi:10.1007/s00228-010-0832-3. PMID 20473658.
- ↑ Gundling F, Harms RT, Schiefke I, Schepp W, Mössner J, Teich N (2008). "Self assessment of warning symptoms in upper gastrointestinal bleeding". Dtsch Arztebl Int. 105 (5): 73–7. doi:10.3238/arztebl.2008.0073. PMC 2701246. PMID 19633787.