Upper gastrointestinal haemorrhage can be a horrible cause of death. A bleed within the upper gastrointestinal tract can occur for many reasons, which we will discuss in this blog post. Often presenting with blood in the vomit; haematemesis, bright red or clotted blood, coffee-ground dark denatured blood or it might present with melaena, black, tarry, smelly stool containing digested blood. Due to the blood loss patients can feel dizzy and faint.
In an emergency department situation it is first essential to complete an A-E assessment and deciding whether this patient is high risk or low risk using something called the Glasgow Blatchford Score (GBS). This is used to work out how systemically unwell the patient is and the amount of blood loss that has already occurred/expecting to occur.
GBS – 1 point is given to each of the following
- Heart rate >100 beats/min
- Systolic BP <100mmHg
- Syncope or postural hypotension
- Urea >6.5mmol/L
- Hb<130g/L in males or <120g/L in females
- Heart failure or liver disease
If the patient scores one or more they are at high risk and need admitting to hospital. Initially this should be managed with blood products, fluids, reversing any anticoagulation and giving antibiotics depending on the clinical presentation. Once stable the cause needs to be investigated to allow for further treatment, usually this involves an endoscopy as an outpatient.
The causes of upper gastrointestinal bleed are shown in the image:
Oesophageal tumour – typically either an adenocarcinoma or a squamous cell carcinoma. Adenocarcinoma might be precipitated by gastroesophageal reflux disease and Barrett’s oesophagus. This can be diagnosed on endoscopy and biopsied at this point too. Treatment options involve resection of the tumour, chemotherapy, radiotherapy and palliative stenting of the tumour. Haematemesis and melena are relatively uncommon signs of oesophageal tumour, it is more likely to present with progressive dysphagia (difficulty swallowing).
Mallory-Weiss Tear – this occurs after multiple episodes of vomiting. The vomiting damages the mucosal membrane of the oesophagus to such an extent that it bleeds. This is often related to alcoholism. This condition can be treated during endoscopy, with the injection of adrenaline to stop the bleeding.
Oesophagitis – inflammation of the oesophagus, mainly caused by gastroesophageal reflux disease. Or it may result from an infection such as herpes simplex or candida (this is more common in the immunocompromised patient)
Oesophageal varices – this condition occurs in patients with liver disease leading to portal hypertension. The increased pressure within this system caused the blood to back up the venous system resulting in dilated, tortuous submucosal veins in the oesophagus. These can rupture causing severe bleeding. When a patient presents with a gastrointestinal bleed, signs of liver disease should be examined.
Gastric carcinoma – adenocarcinomas are the most common. This again is detected on endoscopy and can be biopsied. Bleeding is a less common sign, the patient is more likely to present with nonspecific symptoms such as upper abdominal discomfort and later on weight loss and anaemia.
Angiodysplasia – this is a small vessel malformation of the gastrointestinal system. Most commonly affecting the colon however can affect any part of the gastrointestinal tract. Blood loss can be subtle. Development is related to age and the amount of strain on the bowel wall. It is a lesion that is acquired and results from increased stress on that area of gastrointestinal tract.
Gastric & duodenal ulcer – these are ulcers in either the stomach or the lining of the duodenum. There are a few common causes of these ulcers which include helicobacter pylori, a bacterium, or nonsteroidal anti-inflammatory medicine use e.g. ibuprofen. H.pylori infections can be treated with triple therapy, two antibiotics and an proton pump inhibitor such as omeprazole which protects the stomach lining. Omeprazole can also be given to those taking regular anti-inflammatory medications to prevent ulcers from occurring.
Gastritis – this produces coffee-ground vomit as the blood has mixed and started to be digested by the acid within the stomach. Gastritis is caused by chronic inflammation of the gastric mucosa with gland loss and metaplastic changes.