Upper gastrointestinal bleeding history and symptoms

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, maroon stool, or hematochezia if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage. Patients may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath. Obtaining the history is the most important aspect of making a diagnosis of upper GI bleed. It provides insight into the cause, precipitating factors and associated comorbid conditions and also helps in determining the severity of the bleed as well as in identifying the potential source of bleed.

Obtaining the history is the most important aspect of making a diagnosis of upper GI bleed. It provides insight into the cause, precipitating factors and associated comorbid conditions and also helps in determining the severity of the bleed as well as in identifying the potential source of bleed. Patients may be disoriented, therefore, the patient interview may be difficult. In such cases, history from the care givers or the family members may need to be obtained. ^[1][2]

• A history of epigastric pain, dyspepsia, or prior peptic ulcer may suggest the diagnosis of peptic ulcer disease.^[3]
• A history of documented prior upper GI bleeding is important because approximately 60% of upper GI bleeders are rebleeding from the same site.
• A history of pancreatitis suggests possible hemorrhage from a pancreatic pseudocyst. Erosion of a pancreatic pseudocyst into the duodenum or stomach may cause massive hematemesis, and the patient may present in shock.^[4][5][6]
• Patients with renal failure frequently have GI bleeding. This bleeding is often due to peptic ulcer disease or angiodysplasia. This bleeding may be severe because of clotting dysfunction associated with renal disease.^[7][8]

• Prior use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) is important because these patients have an increased risk of gastric ulcer and a fourfold risk of significant GI bleeding compared with other patients.^[9]

• A history of alcoholism increases the likelihood of cirrhosis and consequently of bleeding from esophageal varices or congestive gastropathy but alcoholics also frequently have peptic ulcers or gastritis.^[10][9]
• Cigarette smokers have a significantly higher rate of the recurrent duodenal ulcer as compared with nonsmokers and a history of cigarette smoking should be elicited.
• Vomiting, coughing, or retching before bleeding is suggestive of a Mallory-Weiss tear.^[11][12]

• Patients with prior abdominal aortic aneurysm repair may present with severe GI hemorrhage from an aortoenteric. This fistula often presents with a herald bleed followed within 4 to 96 hours by massive bleeding.^[13]

• A personal or family history of recurrent epistaxis may suggest the diagnosis of Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia), and a careful examination for skin telangiectasias should be performed. ^[14]

• Upper GI bleeding occurs proximal to the ligament of Treitz.^[15]
• Patients with upper GI bleeding usually present with hematemesis or melena.^[16]
• In large series, about 50% of patients have hematemesis and melena, about 30% have hematemesis alone, and about 20% have only melena.^[17]
• On occasion, however, hematochezia may be the only manifestation of a bleeding ulcer, and about 15% of all patients who present with hematochezia have an upper GI source.
• Peptic ulcer disease is the most common cause of acute upper GI hemorrhage, accounting for about 40% of cases.
• Other common causes are esophageal and gastric varices and erosive esophagitis, variceal bleeding, which occurs in the setting of portal hypertension.
• Other conditions, such as Mallory-Weiss tears, angiodysplasia, watermelon stomach, tumors, and Dieulafoy lesion, occur less frequently than peptic ulcer.
• The mortality from nonulcer bleeding is comparable to that from ulcer hemorrhage in high-risk patients, so all causes of upper GI hemorrhage contribute to the morbidity and cost of care associated with it.^[18]

• Hematemesis: vomiting fresh red blood.
• Coffee ground emesis: vomiting of altered black blood.
• Melena: passage of black tarry stools.
• Hematochezia: Passage of red blood per rectum (usually due to bleeding from the lower gastrointestinal tract but occasionally can be due to massive upper gastrointestinal bleeding).
• Rebleeding: Defined as fresh haematemesis or melaena associated with the development of shock (pulse greater than 100 beats/min, systolic pressure less than 100 mm Hg), a fall in CVP greater than 5 mm Hg, or a reduction in haemoglobin concentration greater than 20 g/l over 24 hours. Rebleeding should always be confirmed by endoscopy

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