Upper gastrointestinal bleeding
Upper gastrointestinal bleeding is acute or chronic bleeding from the upper parts of the digestive tract, namely the esophagus, stomach, and duodenum.
Causes
The most common causes are peptic ulcer, gastric and esophageal varices, and malignant tumors of the stomach, esophagus, and duodenum.
Rarer causes include esophagitis, angiodysplasia, Dieulafoy ulcer (dilated submucosal vessel), and Mallory-Weiss syndrome (elongated mucosal erosion in the lower esophagus).
Peptic ulcers are usually caused by Helicobacter pylori infection or by taking specific medications, such as antiplatelet drugs (clopidogrel, aspirin), nonsteroidal anti-inflammatory drugs, and others. Smoking and alcohol consumption can also increase the risk of developing a peptic ulcer.
Esophageal and stomach varices develop in the context of advanced liver disease (cirrhosis) or increased pressure in the portal vein system of other etiology.
Upper gastrointestinal bleeding – Symptoms
The clinical picture of upper gastrointestinal bleeding also differs depending on the amount of blood lost.
Small chronic blood loss can remain asymptomatic for a long time and be diagnosed during an investigation for anemia.
In case of loss of a larger amount of blood, then there may be clinically:
- defecation with black – like tar – stools (melena defecation)
- vomiting with excretion of coffee-like fluids.
An acute hemorrhage with excretion of a large amount of blood can lead to:
- vomiting with excretion of pure, red blood as well as
- hematochezia, i.e. excretion of pure blood from the rectum.
In cases of acute hemorrhage, the patient is likely to experience:
- weakness,
- pallor,
- tachycardia,
- sweating,
- confusion,
- or even loss of consciousness and immediate transfer to a health facility is necessary.
Diagnosis
The first step is always the initial assessment of the patient’s general condition. Then the diagnosis of the bleeding site and finally its treatment.
In the clinical examination, vital signs are continuously monitored and the patient is stabilized with crystalloid fluids in case of peripheral circulatory instability. Laboratory tests (complete blood count, urea, cross-linking, and clotting times) and emergency blood transfusion are performed if necessary. It is important to take a detailed history regarding medication, previous therapeutic interventions in the digestive tract, surgeries, liver diseases, and possible weight loss.
Upper digestive tract bleeding – Treatment
The treatment for upper digestive tract bleeding is both pharmaceutical and endoscopic, but also through vessel embolization or surgery.
Endoscopic investigation and treatment of acute and visible bleeding is done through gastroscopy.
In the case of gastric or duodenal ulcer, Dieulafoy ulcer, and Mallory-Weiss erosion, a submucosal injection of a vasoconstrictor substance is performed through a catheter with a needle that is advanced to the bleeding site. Also, thermocoagulation through an analogous thermocoagulation catheter (APC), to glue the wall of the bleeding vessel.
An additional mechanical method of stopping bleeding is the placement of a hemostatic Clip, through the working channel of the endoscope. The combination of two of the above methods has better results than monotherapy.
When upper digestive bleeding is due to angiodysplasias of the stomach and duodenum, they are controlled endoscopically with thermocautery of the vessel (APC).
In patients without aggravating factors, but who have undergone two failed attempts at endoscopic hemostasis, in high-risk patients after one attempt at endoscopic hemostasis, or finally in patients who have received at least 5 units of packed red blood cells in 24 hours, either embolization of the bleeding vessel or surgical treatment is recommended.
The treatment of esophageal and gastric variceal bleeding requires pharmacological treatment with the administration of vasoactive drugs and endoscopic therapy.
Here, the endoscopic methods used are ligation of esophageal varices with elastic rings (banding) and sclerotherapy.
In cases where upper gastrointestinal bleeding is massive and the bleeding vessel is not visible, an attempt can be made to mechanically stop the bleeding by placing a Sengstaken catheter. This catheter has 2 balloons, one for the stomach and one for the esophagus. By inflating the balloon, mechanical pressure/tamponade is applied in order to control bleeding.
Rarely and when the above techniques fail, patients undergo TIPS surgery (transjugular transhepatic portal-systemic anastomosis), in which an anastomosis ring is placed between a branch of the hepatic vein and a branch of the portal vein, in order to reduce pressure in the latter and stop bleeding.
In addition to endoscopic treatment, pharmaceuticals also play a crucial role, with the administration of high doses of proton pump inhibitors that ensure an increase in the pH of the stomach. In this way, they contribute to the healing of erosions and ulcers, to the maintenance of the clot that has formed at the site of bleeding, and to the prevention of recurrence of bleeding.
Conclusion
In conclusion, upper gastrointestinal bleeding is a clinical entity that includes a wide range of causes and clinical manifestations, for the treatment of which we currently have advanced interventional techniques.
