View source for Undifferentiated upper gastrointestinal bleeding

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==Background==

[[File:Figure 34 01 10f.png|thumb|Gasterointestinal anatomy.]]
[[File:Layers of the GI Tract english.png|thumb|Layers of the Alimentary Canal. The wall of the alimentary canal has four basic tissue layers: the mucosa, submucosa, muscularis, and serosa.]]
*Bleeding originating proximal to ligament of Treitz
*In the acute setting, the hemoglobin/hematocrit may be normal until dilutional [[Special:MyLanguage/anemia|anemia]] appears after volume resuscitation
*Older patients -> [[Special:MyLanguage/peptic ulcer disease|peptic ulcer disease]], [[Special:MyLanguage/esophagitis|esophagitis]], [[Special:MyLanguage/gastritis|gastritis]]; younger patients -> [[Special:MyLanguage/Mallory-Weiss tear|Mallory-Weiss tear]]s, GI [[Special:MyLanguage/varices|varices]], gastropathy


===Mortality<ref>Kumar R, Mills AM. GI Bleeding. EM Clin N Am. 2011; 29:239-52.</ref>===

*[[Special:MyLanguage/Peptic ulcer disease|Peptic ulcer disease]] = 4%
*[[Special:MyLanguage/Variceal bleeding|Variceal bleeding]] = 50%


===Risk Factors===

*Medications
**[[Special:MyLanguage/ASA|ASA]], [[Special:MyLanguage/steroids|steroids]], [[Special:MyLanguage/anticoagulants|anticoagulants]], chemotherapeutic agents
**[[Special:MyLanguage/NSAIDs|NSAIDs]]<ref>Gonzalez ELM et al. Variability among NSAIDs in risk of upper GI bleeding. Arthritis & Rheumatism. 2010; 62(6): 1592-1601.</ref>
*** RR of bleeding for COX-1 inhibitors is 4.5 (3.82-5.31)
*** RR of bleeding for COX-2 inhibitors is 1.88 (0.96-3.71)
*[[Special:MyLanguage/ETOH abuse|ETOH abuse]]
**[[Special:MyLanguage/Peptic ulcer disease|Peptic ulcer disease]], [[Special:MyLanguage/gastritis|gastritis]], [[Special:MyLanguage/varices|varices]]
*Aortic graft = [[Special:MyLanguage/aortoenteric fistula|aortoenteric fistula]]
*Advanced age (>60 yr)
*Current smoker


==Prehospital==

*'''Airway:''' suction to prevent aspiration, provide oxygen as needed
*'''Breathing''': maintain patient in position of comfort
*'''Circulation:''' monitor for early signs of shock and provide fluid resuscitation if hypotensive. Blood products should be individualized based on local protocols
*[[Special:MyLanguage/Antiemetics|Antiemetics]] can be given to decrease nausea and vomiting
*Assume the patient is hepatitis positive and wear appropriate personal protective gear


==Clinical Features==

[[File:Melena Bleeding DU.jpg|thumb|Melena in a toilet bowel.]]

===History===

*[[Special:MyLanguage/Hematemesis|Hematemesis]]
**Coffee-ground emesis
*[[Special:MyLanguage/Vomiting|Vomiting]] + retching followed by hematemesis is more likely [[Special:MyLanguage/Mallory-Weiss|Mallory-Weiss]] (esophageal)
*[[Special:MyLanguage/Melena|Melena]]
*[[Special:MyLanguage/Syncope|Syncope]] or presyncope
*[[Special:MyLanguage/Dyspepsia|Dyspepsia]], [[Special:MyLanguage/epigastric pain|epigastric pain]] or heartburn


===Physical Exam===

*[[Special:MyLanguage/Tachycardia|Tachycardia]], [[Special:MyLanguage/hypotension|hypotension]]
**Normal vital signs do not preclude the possibility of a severe bleed
*[[Special:MyLanguage/Altered mental status|Altered mental status]] -> poor cerebral perfusion
*Pallor
**In the stable patient may indicate the anemia of a subacute/chronic bleed, in the unstable patient may indicate poor perfusion and massive blood loss
*Liver disease
**Spider angiomata, palmar erythema, [[Special:MyLanguage/jaundice|jaundice]], gynecomastia, [[Special:MyLanguage/hepatomegaly|hepatomegaly]], [[Special:MyLanguage/ascites|ascites]]
*[[Special:MyLanguage/Coagulopathy|Coagulopathy]]
**[[Special:MyLanguage/Petechiae|Petechiae]]/[[Special:MyLanguage/purpura|purpura]]
*ENT exam
**Swallowed blood may result in coffee-ground emesis or melena
*Rectal exam
**Only 20% of patients with a positive fecal occult have an identified upper GI bleed.<ref>Allard J  et al. Gastroscopy following a positive fecal occult blood test and negative colonoscopy: systematic review and guideline. Can J Gastroenterol.2010;24(2):113-120.</ref>


==Differential Diagnosis==

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{{UGIB DDX}}
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==Evaluation==

[[File:Fecal Occult Blood Test.jpg|thumb|Fecal Occult Blood Test showing positive (A) and positive control (B).]]
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{{UGIB evaluation}}
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==Management==

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{{Upper GI bleed treatment}}
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==Disposition==


===Admission===

*Anyone with a [[Special:MyLanguage/Glasgow-Blatchford Bleeding Score|Glasgow-Blatchford Bleeding Score]] above 0 (see discharge section below); consider the clinical Rockall risk score too<ref>Tacke F, Fiedler K, Trautwein C. A simple clinical score pre- dicts high risk for upper gastrointestinal hemorrhages from varices in patients with chronic liver disease. Scand J Gastro- enterol. 2007;42(3):374-382.</ref>
*Age >60yr
*Transfusion required


===Consider Discharge===

''If [[Special:MyLanguage/Glasgow-Blatchford Bleeding Score|Glasgow-Blatchford Bleeding Score]] of 0 (<1% chance of requiring intervention):<ref>Tacke F, Fiedler K, Trautwein C. A simple clinical score pre- dicts high risk for upper gastrointestinal hemorrhages from varices in patients with chronic liver disease. Scand J Gastro- enterol. 2007;42(3):374-382.</ref>.  Must meet ALL of the following:''
*BUN <18
*hemoglobin >13 (men), hemoglobin >12 (women)
*Systemic BP >110
*Heart rate <100
*Patient did NOT present with melena
*Patient did NOT present with syncope
*No hepatic disease
*No cardiac failure


== Calculators ==
{{Glasgow_Blatchford_Calculator}}

==See Also==

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{{GI bleeding pages}}
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==References==

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{{Reflist|2}}
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[[Category:GI]]
[[Category:Symptoms]]
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