Introduction
Upper gastrointestinal bleeding is haemorrhage from a source proximal to the ligament of Treitz, that is from the oesophagus, stomach or duodenum, and occasionally from the proximal jejunum or the biliary and pancreatic tracts. It is a common emergency that can become life-threatening within hours. A good exam answer covers the sources of bleeding, the clinical picture, the stepwise resuscitation and diagnosis, and the endoscopic, pharmacological, radiological and surgical options.
Sources of bleeding
The most important sources differ in frequency, mechanism and typical bleeding pattern. The main ones are summarised below.
Clinical features
- Haematemesis: vomiting of fresh blood or coffee-ground material, the latter being partly digested blood.
- Melaena: black, tarry, foul-smelling stools, which need a substantial blood loss and some transit time to appear. They point to an upper source but do not exclude a right colonic or small bowel one.
- Haematochezia (fresh blood per rectum) can accompany brisk upper bleeding with haemodynamic instability.
- Signs of blood loss: tachycardia, hypotension, postural drop in blood pressure, pallor, cold clammy skin, restlessness, syncope, reduced urine output.
- Chronic or occult loss: iron-deficiency anaemia, fatigue, dyspnoea on exertion.
- Clues to the cause: NSAID, aspirin, anticoagulant or alcohol use; dyspepsia and epigastric pain related to meals; weight loss; dysphagia; history of liver disease, jaundice, ascites, spider naevi or splenomegaly (portal hypertension); previous aortic surgery.