Common
Peptic ulcer (accounts for ∼50%), erosions (gastropathy from alcohol, aspirin, NSAIDs, stress), esophagitis, Mallory-Weiss tear (mucosal tear at gastroesophageal junction due to retching), gastroesophageal varices.
Less Common
Swallowed blood (nosebleed); esophageal, gastric, or intestinal neoplasm; anticoagulant and fibrinolytic therapy; hypertrophic gastropathy (Ménétrier's disease); aortic aneurysm; aortoenteric fistula (from aortic graft); arteriovenous malformation; telangiectases (Osler-Weber-Rendu syndrome); Dieulafoy lesion (ectatic submucosal vessel); vasculitis; connective tissue disease (pseudoxanthoma elasticum, Ehlers-Danlos syndrome); blood dyscrasias; neurofibroma; amyloidosis; hemobilia (biliary origin).
After hemodynamic resuscitation (see next and Fig. 43-1. Suggested Algorithm for Pts with Acute Upper GI Bleeding).
- History and physical examination: Drugs (increased risk of upper and lower GI tract bleeding with aspirin and NSAIDs), prior ulcer, bleeding history, family history, features of cirrhosis or vasculitis, etc. Hyperactive bowel sounds favor upper GI source.
- Nasogastric aspirate for gross blood, if source (upper versus lower) not clear from history; may be falsely negative in up to 16% of pts if bleeding has ceased or duodenum is the source. Testing aspirate for occult blood is meaningless.
- Upper endoscopy: Accuracy >90%; allows visualization of bleeding site and possibility of therapeutic intervention; mandatory for suspected varices, aortoenteric fistulas; permits identification of “visible vessel” (protruding artery in ulcer crater), which connotes high (∼50%) risk of rebleeding.
- Upper GI barium radiography: Accuracy ∼80% in identifying a lesion, though does not confirm source of bleeding; acceptable alternative to endoscopy in resolved or chronic low-grade bleeding.
- Selective mesenteric arteriography: When brisk bleeding precludes identification of source at endoscopy.
- Radioisotope scanning (e.g., 99 Tc tagged to red blood cells or albumin); used primarily as screening test to confirm bleeding is rapid enough for arteriography to be of value or when bleeding is intermittent and of unclear origin.