GASTROINTESTINAL BLEEDING, UPPER   33A

A 74-year-old man with severe osteoarthritis presents to the emergency department reporting two episodes of melena (black stools) without hematochezia (bright red blood in the stools) or hematemesis (bloody vomitus). He takes 600 mg of ibuprofen three times a day to control his arthritis pain. He denies alcohol use. On examination, his blood pressure is 150/70 mm Hg, and his resting pulse is 96 beats/min. His epigastrium is minimally tender to palpation. Rectal examination reveals black tarry stool in the vault, grossly positive for occult blood. Endoscopy demonstrates a 3-cm gastric ulcer. Helicobacter pylori is identified on biopsies of the ulcer site.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Melena; nonsteroidal antiinflammatory drug (NSAID) use; mild tachycardia from anemia; tender epigastrium, stool occult blood positive; endoscopy showing gastric ulcer; biopsy positive for H. pylori

How to think through: Upper gastrointestinal (GI) bleeding is a common clinical problem, and rapid initial triage is essential. As soon as melena is confirmed by physical examination, you must determine is if the patient is hemodynamically stable. What is the most sensitive marker of a hemodynamically significant hemorrhage? (An elevated heart rate.) What are key factors in determining if an urgent upper endoscopy is indicated? (Evidence of hemodynamic instability; ongoing bleeding.) How could you assess ongoing hemorrhage? (Nasogastric lavage.) Does hematochezia rule out the upper GI tract as a bleeding source? (No. A brisk upper GI tract bleed may appear as red blood.) Would a normal hematocrit reassure you that a hemorrhage is insignificant? (No.) What is the first priority if you suspect a significant GI bleed? (Intravenous [IV] access.) What are important risk factors to consider for upper GI bleeding? (Alcohol use and other risk factors for cirrhosis, NSAID use, retching [Mallory-Weiss tear], H. pylori risk factors, and symptoms suggesting gastric cancer.) What raises the likelihood of H. pylori? (Patients born in an endemic country; older age.) How is H. pylori treated?

GASTROINTESTINAL BLEEDING, UPPER   33B

What are essentials of diagnosis and general considerations regarding upper gastrointestinal bleeding?

Essentials of Diagnosis

Melena or hematemesis; hematochezia can occur in large, brisk upper GI tract bleeds.

Use volume (hemodynamic) status to determine the severity of blood loss; hematocrit is a poor early indicator of blood loss.

Endoscopy is diagnostic and may be therapeutic.

General Considerations

Hematemesis is either bright red blood or brown “coffee grounds” material.

Melena develops after as little as 50 to 100 mL of blood loss.

Hematochezia requires more than 1000 mL of blood loss.

Upper GI bleeding is self-limited in 80% of cases; urgent medical therapy and endoscopic evaluation are required in the remainder.

Peptic ulcers account for about 50% of cases; variceal bleeding accounts for 10% to 20% of cases.

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