Upper gastrointestinal (GI) bleeding, which is defined as blood loss originating near the Treitz ligament, is a common cause of hospitalization and mortality. Symptoms include hematemesis, coffee ground emesis, red blood return with nasogastric aspiration, melena, and hematochezia with heavy bleeding. The first step in managing upper GI bleeding is stabilizing the patient and obtaining a thorough medical history to identify potential causes of GI hemorrhage. Transfusion is appropriate if blood loss is significant. Intravenous or oral proton pump inhibitors (PPIs) can help reduce gastric lining irritation. Researchers have found that somatostatin and its analog octreotide (Sandostatin) reduced portal blood flow to the stomach and duodenum, resulting in decreased risk of continuous hemorrhage and surgical intervention. These actions may be considered temporary treatments before endoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) Practice Committee recently reviewed prospective trials, series reports, and expert opinions on the role of endoscopy in managing acute nonvariceal upper GI bleeding.
Endoscopy is most beneficial when initiated soon after upper GI bleeding begins and can decrease the duration of hospitalization and the need for transfusion. Intravenous erythromycin administered before endoscopy promotes gastric emptying and improves the diagnostic quality of the examination. Emergency department physicians can assess the risk for recurrent bleeding and recommend outpatient treatment or possible endoscopic treatment. Signs of high-risk bleeding include active arterial bleeding, nonbleeding visible vessels, nonbleeding adherent clots, and ulcer oozing.
Peptic ulcer disease (usually brought on by nonsteroidal anti-inflammatory medications or Helicobacter pylori infection) is the most common cause of upper GI bleeding. Endoscopic therapy including laser treatment, electrocautery, heat probe, and epinephrine injection (with or without additives) are all effective compared with placebo or no treatment. The success of these modalities usually is determined by the skill of the physician performing them. Physicians should test patients with upper GI bleeding for H. pylori through biopsy, because rapid urease tests have reduced sensitivity in this setting. Patients with positive test results should be treated to eradicate the infection.
Other causes of upper GI bleeding include esophageal lesions, vascular abnormalities, aortoenteric fistulas, and GI tumors. Esophagitis rarely requires endoscopic treatment unless a patient has ongoing or severe bleeding from Mallory-Weiss tears. Multipolar electrocautery is the most effective method to manage Mallory-Weiss tear bleeds. Vascular abnormalities can occur on their own or in association with other conditions (e.g., cirrhosis, collagen vascular disease, radiation injury). The overall value of endoscopic treatments for vascular abnormalities is unclear, but endoscopic therapy may successfully manage large-caliber submucosal arterial bleeding in some patients. Aortoenteric fistulas generally occur beyond the reach of most endoscopes, at the distal duodenum or jejunum, making surgery the most effective treatment. GI tumors can be managed initially through endoscopic therapy, but the patient may require surgery or angiographic intervention to decrease long-term hemorrhage risk.
Upper GI bleeding recurrence after endoscopic therapy can occur in up to 24 percent of high-risk patients. Adding PPI therapy to endoscopic treatment, however, reduces the risk to 10 percent. The authors suggest that repeat endoscopic surveillance is appropriate for patients with high-risk lesions, but the precise role of endoscopy for recurrent bleeding has yet to be defined.
The ASGE Practice Committee concluded that endoscopy is effective in the diagnosis and treatment of upper GI bleeding, although the superiority between the individual endoscopic treatments has not been determined. The committee recommends that patients with a high risk of recurrent bleeding receive closer monitoring and possible repeat endoscopy.