Upper gastrointestinal bleeding is bleeding that occurs in the upper part of the digestive tract, including the esophagus, stomach, or duodenum. It can cause vomiting blood or coffee-ground-like material, as well as black, tarry stools or bright red blood in the stool.
Other symptoms may include severe weakness, pale skin, a rapid heartbeat, and drowsiness. In severe cases, substantial blood loss can lead to hypovolemic shock, which is a life-threatening emergency.
Upper gastrointestinal bleeding is commonly caused by stomach or duodenal ulcers associated with H. pylori infection or the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Anyone with signs of severe bleeding should seek emergency medical care as soon as possible.
Main symptoms
The main symptoms of upper gastrointestinal bleeding are:
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Vomiting bright red blood or blood clots, known as hematemesis
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Vomit that looks like coffee grounds
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Black, tarry stools
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Bright red blood in the stool when the bleeding is severe
In more serious cases, substantial blood loss may cause hypovolemic shock. Symptoms can include severe weakness, pale skin, a rapid heartbeat, drowsiness, confusion, low blood pressure, or rapid breathing.
Hypovolemic shock can be life-threatening without prompt treatment. Anyone with these symptoms, especially after vomiting blood or passing blood in the stool, should seek emergency medical care immediately.
Confirming a diagnosis
Upper gastrointestinal bleeding is usually evaluated by an emergency physician, primary care provider, hospitalist, or gastroenterologist.
The healthcare team will assess the symptoms, when they began, how severe they are, and whether there are signs of significant blood loss. They will also review the patient's medical history, including the use of NSAIDs, blood-thinning medications, and alcohol.
According to the American College of Gastroenterology, patients hospitalized with upper gastrointestinal bleeding should generally undergo endoscopy within 24 hours of presentation.
CT angiography may be used when bleeding continues and the source cannot be identified with endoscopy, when endoscopic treatment is unsuccessful, or when endoscopy cannot be performed.
Blood tests are also commonly performed, including a complete blood count (CBC), coagulation tests, and liver function tests. These tests help assess the severity of blood loss and identify conditions that may contribute to bleeding, such as cirrhosis or a blood-clotting disorder.
Possible causes
The main causes of upper gastrointestinal bleeding are:
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Stomach or duodenal ulcers
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Gastroesophageal varices
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Stress gastritis
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Duodenitis
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Dieulafoy lesion
Less common causes include stomach, esophageal, or duodenal cancer, blood vessel malformations, and abnormal connections between blood vessels and the digestive tract.
Depending on the cause, other symptoms may develop before the bleeding episode, such as abdominal pain, painful swallowing, or yellowing of the skin or eyes. It is important to tell a healthcare provider about these symptoms because they may help identify the cause of the upper gastrointestinal bleeding.
Treatment options
Upper gastrointestinal bleeding is usually treated in a hospital with intravenous fluids and, if needed, a blood transfusion. A gastroenterologist may perform an endoscopy to identify and treat the source.
For nonvariceal bleeding, treatment may include pantoprazole or esomeprazole. After a bleeding ulcer is treated endoscopically, high-dose intravenous proton pump inhibitor therapy is usually given for 72 hours before switching to oral medication.
Endoscopic treatment may include thermal coagulation, clips, or epinephrine injection combined with another method. Epinephrine should not be used alone.
If variceal bleeding is suspected in a person with cirrhosis, intravenous octreotide and antibiotics may be started before endoscopy.
Esophageal varices are usually treated with endoscopic band ligation, while gastric varices may require specialized endoscopic or interventional radiology procedures.