Acute upper gastrointestinal (GI) bleeding is a common and important presentation. It may be caused by a wide variety of conditions but is most commonly due to either oesophageal varices or peptic ulcer disease.
Clinical features
| Cause | Presenting features |
|---|---|
| Oesophageal varices | Usually a large volume of fresh blood. Swallowed blood may cause melena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed. |
| Oesophagitis | Small volume of fresh blood, often streaking vomit. Melena rare. Often ceases spontaneously. Usually history of antecedent GORD-type symptoms. |
| Cancer | Usually small volume of blood, except as a preterminal event with erosion of major vessels. Often associated symptoms of dysphagia and constitutional symptoms such as weight loss. May be recurrent until malignancy is managed. |
| Mallory Weiss tear | Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting. Melena is rare. Usually ceases spontaneously. |
| Cause | Presenting features |
|---|---|
| Gastric ulcer | Small low low-volume bleeds are more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis. |
| Gastric cancer | May be frank haematemesis or altered blood mixed with vomit. Usually prodromal features of dyspepsia and may have constitutional symptoms. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage. |
| Dieulafoy lesion | Often no prodromal features prior to haematemesis and melena, but this arteriovenous malformation may produce quite a considerable haemorrhage and may be difficult to detect endoscopically |
| Diffuse erosive gastritis | Usually haematemesis and epigastric discomfort. Usually, there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise |
Approximately 75% of Dieulafoy's lesions occur in the upper part of the stomach within 6 cm of the gastroesophageal junction, most commonly in the lesser curvature.
| Cause | Presenting features |
|---|---|
| Duodenal ulcer | These are usually posteriorly sited and may erode the gastroduodenal artery. However, ulcers at any site in the duodenum may present with haematemesis, melena and epigastric discomfort. The pain of a duodenal ulcer is slightly different to that of gastric ulcers and often occurs several hours after eating. Periampullary tumours may bleed but these are rare. |
| Aorto-enteric fistula | In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality. |
NICE published guidelines in 2012 on the management of acute upper gastrointestinal bleeding which is most commonly due to either peptic ulcer disease or oesophageal varices. Some of the key points are detailed below.
Risk assessment