Editing Upper GI bleed (section)

== '''Aetiology''' ==

* '''Most commonly EROSIVE (oesophagus, stomach or duodenum) or VARICES'''
** So if varices are not suspected, it's most likely to be erosive
** In liver patients (cirrhosis or portal hypertension), 90% of UGIB are caused by varices
* '''Erosive/ulcerative'''
** Oesophagitis (13%)
*** Chronic exposure to gastric acid leads to an inflammatory response that can result in chronic blood loss, perhaps also with ulcerations
*** Other underlying causes:
**** Infection (candida, HSV, CMV)
**** Crohn disease
**** Radiation
**** Medications (NSAIDs, oral bisphosphonates, tetracyclines)
*** Haematemesis very common, melaena less common
*** Treat with PPI. Endoscopic coagulation is generally successful. Surgery seldom necessary.
** PUD (see separate topic and section below) - about 60% of UGIB
*** 10-15% of patients with PUD will develop bleeding at some point
*** Bleeding ulcers are more frequently associated with NSAIDs than H. pylori, but note that H. pylori tests have reduced sensitivity in bleeding, so this may be an underestimate
*** 75% will stop bleeding with IVF and IV PPI
*** Duodenal ulcers are more likely to stop bleeding spontaneously, and have lower morbidity/mortality rates than gastric ulcers
*** Significant bleeding occurs when the erosion reaches a submucosal artery, or an even larger artery in penetrating ulcers (GDA or LGA)
** Gastritis
*** See separate topic - stress gastritis
** Duodenitis
* '''Complications of portal hypertension'''
** Oesophagogastric varices
*** See separate topic
*** Look for signs of portal hypertension (splenomegaly, thrombocytopaenia, ascites) and stigmata of chronic liver failure (jaundice, palmar erythema, gynaecomastia, spider angiomata, testicular atrophy, Dupuytren's contracture).
*** Often blood in GIT precipitates decompensation in cirrhotics, leading to encephalopathy.
** Ectopic varices
** Portal hypertensive gastropathy
*** Often smaller volume bleeding. Still see signs of portal hypertension/cirrhosis on exam such as splenomegaly.
* '''Vascular lesions'''
** Angiodysplasia
** Dieulafoy's lesion
*** Sudden-onset large volume painless bleeding
*** See separate topic
** Gastric antral vascular ectasia (GAVE syndrome)
*** Collection of dilated venules that appear as a linear red streak converging on the antrum, giving the appearance of a watermelon
*** Associated with cirrhosis/portal HTN, collagen vascular disease (scleroderma), IHD, CKD, pernicious anaemia, and bone marrow transplant recipients
*** Severe haemorrhage is rare, with most patients presenting with persistent iron deficiency anaemia from continued occult blood loss
*** Endoscopic therapy (APC) indicated for persistent anaemia or transfusion-dependent bleeding. Success rate >90%. Typically 2-3 treatments are required, separated every 1-2 months.
*** Consider antrectomy for those that do not respond to endoscopic therapy.
* '''Traumatic/iatrogenic'''
** Mallory-Weiss tears (5-10%)
*** See separate topic
** FB ingestion
** Post-surgical anastomotic bleeding
** Post-instrumentation bleeding
*** Endoscopic sphincterotomy - inject with adrenaline and gold probe
** Aortoenteric fistula
*** Separate topic
** Cameron Lesion
*** Erosions or ulcers occurring in the sac of a hiatal hernia
*** Usually incidental, but can cause bleeding
*** Surgery to repair hiatus hernia can be considered in patients with recurrent bleeding despite conservative management
* '''Tumours'''
** Upper GI tumours such as GIST
*** Usually associated with chronic bleeding rather than acute
*** Often successful in initial control, but with a high rebleeding rate
*** Therefore, resection is indicated when this is diagnosed
**** Palliative: wedge resection
**** Curative: standard oncologic operation
* '''Miscellaneous'''
** Haemosuccus pancreaticus
*** See separate topic
** Haemobilia
*** See separate topic under biliary
** Inflammatory bowel disease
*** Very rare to present as UGIB
*** Can get duodenal ulcer - treat in the usual way
** Swallowed blood (nosebleed)