Gastrointestinal bleeding refers to any bleeding that starts in the gastrointestinal tract, which extends from the mouth to the large bowel. It is a potentially life-threatening abdominal emergency that remains a common cause of hospitalization. The incidence of upper gastrointestinal bleeding (UGIB) is approximately 100 cases per 100,000 population per year1.

The degree of bleeding can range from nearly undetectable (the amount of blood is so small that it can only be detected by laboratory testing) to acute, massive, and life-threatening. Prolonged microscopic bleeding can lead to massive loss of iron, causing anemia. Acute, massive bleeding can lead to hypovolemia, shock, and even death.

Bleeding may also come from any site along the gastrointestinal tract, but is often divided into:

Upper GI bleeding: The upper gastrointestinal (GI) tract is located between the mouth and outflow tract of the stomach.
Lower GI bleeding: The lower GI tract is located from the outflow tract of the stomach to the anus (small and large bowel included).

Bleeding from the upper GI tract is approximately 4 times as common as bleeding from the lower GI tract and is a major cause of morbidity and mortality. Mortality rates from UGIB are 6-10% overall¹.

Causes of UGIB

The commonest cause of upper gastrointestinal bleeding (UGIB) is peptic ulcers. Severe ulcer bleeding is caused by erosion of the artery by the ulcer with the severity depending on the size of ulcer and the defect. Large ulcers in the posterior part of the duodenal cap can erode the gastroduodenal artery and cause rapid bleeding.

Malory-Weiss tears are caused by retching usually associated with alcohol abuse and other signs of GI disease, e.g. peptic ulcer, gastroenteritis or have a cause of vomiting unrelated to the GI tract. Normally, bleeding stops spontaneously.

Bleeding from upper GI neoplasm is normally not severe and rarely fatal on its own. Esophageal varices are relatively uncommon but often cause severe bleeding and are associated with other features of liver disease, e.g. ascites, jaundice, splenomegaly and fluid retention.

Symptoms

Patients with upper GI hemorrhage often present with hematemesis (vomiting of blood), coffee ground vomiting, melena (dark tarry stools), or hematochezia (blood in the feces) if the hemorrhage is severe.

Patients may also present with complications of anemia, including chest pain, syncope (loss of consciousness resulting from insufficient blood flow to the brain), fatigue and shortness of breath.

Diagnostic tests for UGIB

A range of diagnostic tests are ordered for suspected UGIB cases. The initial investigation for UGIB is:

Full Blood Count
Coagulation tests (PT, PTT, INR), platelet count, etc
Esophagogastroduodenoscopy (EGD)

This will determine extent of blood loss and determine if bleeding is from the stomach or duodemum. For cases where bleeding is not from the stomach or duodemum, then tests are needed to determine cause of bleeding:

Colonoscopy
Sigmoidoscopy
Abdominal x-ray
Abdominal CT scan
Capsule endoscopy
Small bowel enteroscopy
Abdominal MRI scan
Bleeding scan (tagged red blood cell scan)
Angiography

UGIB Treatments in NUH

Upper gastrointestinal bleeding (UGIB) is one of the commonest GI emergencies in NUH, with significant mortality and morbidity.

During a 2-year audit performed in 2002-2003, mortality of patients presenting with symptoms of UGIB was 10%^2-6, which is among the standard from renowned international centres. Our low rate of mortality is related to a dedicated multidisciplinary team comprising of doctors from departments of Emergency, General Surgery, and Gastroenterology, and nurses at operating theatre and Endoscopy Centre.

Footnotes

Fallah MA, Prakash C, Edmundowicz S: Acute gastrointestinal bleeding. Med Clin North Am 2000 Sep; 84(5): 1183-208
Ong TZ, Yeoh KG, Ho KY. Digestive Disease Week 2004
Exon SJ, Sydney Chung SC. Endoscopic therapy for upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2005;18:77-98.
Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis: a comprehensive review. Gastrointest Endosc 2004;59:845-64.
Yavorski RT, Wong RK, Maydonovitch C, Battin LS, Furnia A, Amundson DE. Analysis of 3,294 cases of upper gastrointestinal bleeding in military medical facilities. Am J Gastroenterol 1995;90:568-73.
Vreeburg EM, Snel P, de Bruijne JW, Bartelsman JF, Rauws EA, Tytgat GN. Acute upper gastrointestinal bleeding in the Amsterdam area: incidence, diagnosis, and clinical outcome. Am J Gastroenterol. 1997 Feb;92(2):236-43.

This material does not cover all information and is not intended as a substitute for professional care. Please consult with your physician on any matters regarding your health.

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