Upper gastrointestinal haemorrhage

doi:10.1136/bmj.323.7321.1115

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Helen J Dallal,
K R Palmer

Acute upper gastrointestinal haemorrhage accounts for about 2500 hospital admissions each year in the United Kingdom. The annual incidence varies from 47 to 116 per 100 000 of the population and is higher in socioeconomically deprived areas.

Endoscopic stigmata associated with high risk of further gastrointestinal bleeding. Top left: an active, spurting haemorrhage from a peptic ulcer is associated with an 80% risk of continuing bleeding or rebleeding in shocked patients. Top right: a non-bleeding, visible vessel represents either a pseudoaneurysm of an eroded artery or a closely adherent clot, and 50% of such patients rebleed in hospital. Left: large varices with red spots are also strongly associated with bleeding

Although hospital mortality has not improved over 50 years and remains at about 10%, older patients who have advanced cardiovascular, respiratory, or cerebrovascular disease that puts them at increased risk of death now comprise a much higher proportion of cases. Many patients' bleeding is associated with use of non-steroidal anti-inflammatory drugs, but there is no evidence that prognosis is worse in patients who are taking these drugs than in those who are not.

Presentation of bleeding

All patients who develop acute gastrointestinal bleeding need urgent assessment. Almost all should be admitted as an emergency to hospital. Only a small minority of young, fit patients who have self limiting bleeding can be managed as outpatients, but even those need urgent investigation. Patients who present with haematemesis tend to have more severe bleeding than those who present with melaena alone.

Risk factors for death after hospital admission for acute upper gastrointestinal haemorrhage

Advanced age
Shock on admission (pulse rate >100 beats/min; systolic blood pressure <100 mm Hg)
Comorbidity (particularly hepatic or renal failure and disseminated cancer)
Diagnosis (worst prognosis for advanced upper gastrointestinal malignancy)
Endoscopic findings (active, spurting haemorrhage from peptic ulcer; non-bleeding, visible blood vessel; large varices with red spots)
Rebleeding (increases mortality 10-fold)

At the …