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Upper gastrointestinal bleeding

Dr Frank Gaillard and Dr Donna D'Souza et al.

Upper gastrointestinal bleeding usually refers to bleeding proximal to the ligament of Treitz.

Epidemiology

The demographics of the affected individual will depend on the underlying aetiology, which include:

peptic ulcer disease (PUD) : most common, accounting for ~50% of cases ³
gastritis
oesophagitis
duodenitis
Mallory-Weiss tear
varices
tumour
vascular abnormality (vascular ectasia, angiodysplasia, Dieulafoy lesion, vascular malformation).
aorto-duodenal fistula

Clinical presentation

Classically presents with haematemesis and/or maelena. May present with haematochezia if severe bleeding. Slow bleeding may cause iron deficiency anaemia.

Radiographic features

Upper endoscopy is first line investigation and allows for treatment of the bleeding using a variety of endoscopic techniques.

DSA

Angiography and embolisation is used in refractory cases, and is generally preferred over surgery. 85% of upper GI haemorrhage is from the left gastric artery territory. Extra-vascular contrast extravasation indicates the site of active bleeding and may be linear (pseudovein sign) or blotchy. Upper GI embolisation is well tolerated because of the rich collateral blood supply. In a patient with significant bleeding, if no active bleeding site is identified on angiography but there is documented upper GI bleeding on endoscopy or NG aspirates, prophylactic embolisation of the left gastric artery is sometimes performed. If there is a bleeding duodenal ulcer and no active extravasation is documented and patient condition is likely to deteriorate empirical embolisation of gastroduodenal artery territory is recommended to prevent life threatening events.

Nuclear medicine

Nuclear scintigraphy is usually not helpful, as it requires relatively brisk active bleeding to be positive, but is often unable to accurately localise the source, above and beyond 'upper gastrointestinal tract'.