Upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is defined as bleeding proximal to the ligament of Treitz.

The incidence of acute upper GI bleeding is ~100 per 100,000 adults per year. Upper GI bleeding is twice as common in men as in women and increases in prevalence with age 5. The demographics of the affected individual will depend on the underlying aetiology (see below).

Classically presents with haematemesis and/or melena. Although haematemesis and melaena suggest a more proximal source, 15% of patients with upper GI bleeding present with haematochezia. Slow bleeding may cause iron deficiency anaemia 4.

Furthermore, a variceal source should be considered if there is history of liver disease, cirrhosis or excessive alcohol use, haematemesis or haematocheiza, or if examination reveals stigmata of chronic liver disease.4

Risk factors include:5

  • medication, e.g. warfarin, NSAIDs, aspirin, SSRI, corticosteroids
  • previous history of UGIB
  • previous abdominal surgery
  • chronic renal or liver disease

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

There are some values of using CT as the 'next step' technique in identifying a bleeding source within the GIT following negative or failed endoscopy in the acute setting 6.

Arterial imaging is best performed when active acute bleeding is ongoing. Findings on CT include extravasated contrast identified as a focal area of high attenuation within the bowel lumen which represents a bleeding point 6.

A non-contrast scan needs to be done first to exclude any false-positive reading on arterial phase imaging 6.

Other findings are largely related to the particular underlying cause such as tumours, inflammatory bowel disease, ischaemic colitis and vascular abnormalities 6.

Active bleeding will not be seen and the purpose of imaging is to diagnose the cause of bleeding rather than identify the actual bleed.

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 (pseudo-vein 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 the patient condition is likely to deteriorate empirical embolisation of gastroduodenal artery territory is recommended to prevent life-threatening events.

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'.

Despite advances in therapy, the in-hospital mortality rate remains high (13%) and re-bleeding is common (15%) 5.

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Article information

rID: 4678
Tag: rewrite
Synonyms or Alternate Spellings:
  • Upper GI haemorrhage
  • Upper GI hemorrhage
  • Upper gastrointestinal tract haemorrhage
  • Upper gastrointestinal tract hemorrhage
  • Upper gastrointestinal bleeding (UGIB)

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Cases and figures

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    Left hepatic arte...
    Case 1: left hepatic artery - post embolisation
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    Left gastric arte...
    Case 1: vascular blush - left gastric artery blush
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    Case 2: bleeding gastric ulcer
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    Case 3
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