Acute severe upper gastrointestinal haemorrhage is an important medical emergency.
A sudden loss of 20% or more circulatory blood volume usually produces signs of shock, such as tachycardia, hypotension, faintness and sweating.
Table H1 Haematemesis: diagnostic strategy model
Chronic peptic ulcer (stomach and duodenum) 50%
Acute gastric ulcers/erosions 20%
Oesophagitis (incl. GORD)
Mallory–Weiss (emetogenic) syndrome
Drugs: aspirin, NSAIDs, anticoagulants, clopidogrel, ingested poisons
Serious disorders not to be missed
Pitfalls (often missed)
Swallowed blood (e.g. epistaxis)
Collagen diseases (e.g. scleroderma)
Note: In many cases, no visible cause can be identified.
Nature of vomitus from fresh blood to ‘coffee grounds’
Is bleeding arising from the mouth, nose or pharynx?
Indigestion, heartburn or stomach pains
Associated symptoms (e.g. weight loss, jaundice)
Any bleeding problems
Drug history including alcohol, NSAIDs, antiplatelet agents, warfarin, steroids
Patient’s general state including circulation, vital signs
Abdominal examination and rectal examination
Evidence of liver disease
Upper GIT endoscopy diagnoses bleeding source in 80%
LFTs including γ GT
Helicobacter pylori tests
Imaging (e.g. plain erect X-ray, as indicated)
Causes of upper GI bleeding The major cause of bleeding is chronic peptic ulceration of the duodenum and stomach, which accounts for approx. half of all cases. The other major cause is acute gastric ulcers and erosions, which account for at least 20% of cases. Aspirin and NSAIDs are responsible for many of these bleeds. Causes are illustrated in Figure H1.
Important upper GI causes of haematemesis and melaena
Investigations Investigations to determine the source of the bleeding should be carried out in a specialist unit. Endoscopy will detect the cause of the bleeding in at least 80% of cases.
The immediate objectives are:
restore an effective blood volume (if necessary)
establish a diagnosis to allow definitive treatment
All patients with a significant bleed should be admitted to hospital and referred to a specialist unit. Urgent resuscitation is required where there has been a large bleed and there are clinical signs of shock. Such patients require an intravenous line inserted and transfusion with blood cells or fresh frozen plasma (or both), commenced as soon as possible.
In many patients bleeding is insufficient to decompensate the circulatory system and they settle spontaneously. Approximately 85% of patients stop bleeding within 48 hrs. PPIs should be commenced in most cases since most bleeds are from peptic ulceration. Use oral ...