Gastrointestinal Bleeding, Upper
Sara Karjoo
Chris A. Liacouras
INTRODUCTION
The presence of hematemesis usually suggests that the site of bleeding is proximal to the ligament of Treitz. Common sites of upper gastrointestinal (GI) tract bleeding are summarized in Table 35-1.
DIFFERENTIAL DIANGOSIS LISTInfectious Causes
Bacterial gastritis—Helicobacter pylori infection
Viral infection—Cytomegalovirus, varicella, herpesvirus, adenovirus
Fungal esophagitis or gastritis
Toxic Causes
Drugs—nonsteroidal antiinflammatory drugs (NSAIDs), aspirin, steroids
Caustic substances
Alcohol gastritis
Neoplastic Causes
Zollinger-Ellison syndrome
Leiomyoma
Leiomyosarcoma
Lymphoma
Upper GI tract polyps
Traumatic Causes
Mallory-Weiss tear
Epistaxis
Oropharyngeal trauma (e.g., postsurgical trauma)
Nasogastric or gastric tube trauma
Foreign body
Congenital or Vascular Causes
Enteric duplication
Ulcer with Dieulafoy lesion
Arteriovenous malformation
Esophageal or gastric varices
Inflammatory Causes
Gastric or duodenal ulcer
Esophagitis (reflux or chemical)
Gastritis (caustic or chemical)
Duodenitis
Eosinophilic gastritis
Miscellaneous Causes
Hemobilia
Graft-versus-host disease
Swallowed maternal blood
Pulmonary disease (hemoptysis)
Factitious bleeding (Munchausen by proxy syndrome)
TABLE 35-1 Causes of Hematemesis by Site | ||||||||||
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DIFFERENTIAL DIAGNOSIS DISCUSSION
Mallory-Weiss Tear
Etiology
A Mallory-Weiss tear is a linear mucosal tear of the distal esophagus that occurs as a result of forceful vomiting or retching.
Clinical Features
Bloody streaks are seen in the vomitus.
Evaluation
Mallory-Weiss tears are not visible on radiographs, and definitive diagnosis is via upper endoscopy. Initially, the tear appears as a vertical, linear red streak; after healing, it is seen as a white streak with surrounding erythema. Most times, it is suspected from clinical history and tests are not needed. In any case of hematemesis or coffee ground emesis, nasogastric tube should be placed and normal saline gastric lavage should be performed.
Treatment
Most patients can be managed in the outpatient setting because Mallory-Weiss tears usually resolve spontaneously. In severe cases, hospital observation is indicated. Rarely, blood transfusion, vasopressin therapy, or balloon tamponade may be necessary.
Esophagitis
Etiology
Esophagitis (inflammation of the esophageal mucosa) can be caused by acid or bile reflux, infection, inflammation, allergy, or caustic ingestions. Esophagitis may result from disorders that promote delayed gastric emptying secondary to vomiting acidic stomach contents.
Clinical Features
Typically, patients complain of heartburn, chest pain, water brash (sour taste in the mouth), dysphagia, halitosis, vomiting, and/or regurgitation. Bloodstreaked emesis occurs in patients with severe or untreated esophagitis.
In infants with severe reflux esophagitis, parents may notice pooled bloody secretions on the infant’s bedding. In older children with esophagitis, bloody emesis is usually associated with epigastric or chest pain and a history of frequent regurgitation and a “sour taste” in the mouth.
Evaluation
Upper endoscopy is the preferred test because it allows for inspection of the esophageal mucosa. Biopsies of the esophagus can be taken to determine the cause of the inflammation and the degree of histologic involvement.
Upper GI tract radiography is often useful for determining the anatomic configuration of the upper GI tract. This study is most valuable for ruling out other causes of upper GI bleeding (e.g., gastric or duodenal ulcer disease, esophageal strictures).
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