Upper gastrointestinal bleeding
Upper gastrointestinal bleeding (UGIB) is defined as bleeding proximal to the ligament of Treitz.
The incidence of acute UGIB is ~100 per 100,000 adults per year. UGIB 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 UGIB present with haematochezia. Slow bleeding may cause iron deficiency anaemia 4.
Furthermore, a variceal source should be consider 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
- peptic ulcer disease (PUD) (>60% 5)
- varices (~20% 4)
- tumour, e.g. oesophageal or gastric cancer, GIST
- Mallory-Weiss tear
- vascular abnormalities
- aorto-duodenal fistula
Risk factors includes: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.
Non-contrast scan need 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.
Chronic or occult bleeding
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 (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 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'.
Treatment and prognosis
Despite advances in therapy, the in-hospital mortality rate remains high (13%) and re-bleeding is common (15%) 5.
- 1. Kandarpa K & Aruny J, Handbook of Interventional Radiologic Procedures, 3rd edition, Lippincott Williams & Wilkins 2002
- 2. Weissleder R. Primer of diagnostic imaging. Mosby Inc. (2007) ISBN:0323040683. Read it at Google Books - Find it at Amazon
- 3. DiMarino AJ, Benjamin SB. Gastrointestinal Disease, An Endoscopic Approach. Slack Incorporated. (2002) ISBN:1556425112. Read it at Google Books - Find it at Amazon
- 4. Lu Y, Loffroy R, Lau JY et-al. Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding. Br J Surg. 2014;101 (1): e34-50. doi:10.1002/bjs.9351 - Pubmed citation
- 5. Wilkins T, Khan N, Nabh A et-al. Diagnosis and management of upper gastrointestinal bleeding. Am Fam Physician. 2012;85 (5): 469-76. Pubmed citation
- 6. Stunell H, Buckley O, Lyburn ID et-al. The role of computerized tomography in the evaluation of gastrointestinal bleeding following negative or failed endoscopy: a review of current status. J Postgrad Med. 2009;54 (2): 126-34. Pubmed citation