View source for Upper gastrointestinal bleeding

{{Short description|Bleeding of the esophagus, stomach, or upper intestine}}
{{Infobox medical condition
| name            = Upper gastrointestinal bleeding
| synonyms        = Upper gastrointestinal hemorrhage, gastrorrhagia
| image           = DU 2.jpg
| caption         = Endoscopic image of a posterior wall [[duodenal ulcer]] with a clean base, which is a common cause of upper gastrointestinal hemorrhage.
| pronounce       =
| field           = [[Gastroenterology]]
| symptoms        = [[Hematemesis]] (vomiting blood), [[coffee ground vomiting]], [[melena]], [[hematochezia]] (maroon-coloured stool) in severe cases
| complications   =
| onset           =
| duration        =
| types           =
| causes          =
| risks           =
| diagnosis       =
| differential    =
| prevention      =
| treatment       =
| medication      =
| prognosis       =
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| deaths          =
}}

<!-- Definition and symptoms -->
'''Upper gastrointestinal bleeding''' ('''UGIB''') is [[gastrointestinal bleeding]] in the [[upper gastrointestinal tract]], commonly defined as bleeding arising from the [[esophagus]], [[stomach]], or [[duodenum]]. Blood may be observed in [[vomit]] or in altered form as [[melena|black stool]]. Depending on the amount of the blood loss, symptoms may include [[shock (circulatory)|shock]].

<!-- Cause and diagnosis -->
Upper gastrointestinal bleeding can be caused by [[peptic ulcer]]s, [[gastric erosion]]s, [[esophageal varices]], and rarer causes such as [[gastric cancer]]. The initial assessment includes measurement of the [[blood pressure]] and [[heart rate]], as well as [[blood test]]s to determine the [[hemoglobin]].

<!-- Treatment  -->
Significant upper gastrointestinal bleeding is considered a [[medical emergency]]. [[Fluid replacement]], as well as [[blood transfusion]], may be required. [[Endoscopy]] is recommended within 24 hours and bleeding can be stopped by various techniques.<ref name=Bar2019>{{cite journal |last1=Barkun |first1=AN |last2=Almadi |first2=M |last3=Kuipers |first3=EJ |last4=Laine |first4=L |last5=Sung |first5=J |last6=Tse |first6=F |last7=Leontiadis |first7=GI |last8=Abraham |first8=NS |last9=Calvet |first9=X |last10=Chan |first10=FKL |last11=Douketis |first11=J |last12=Enns |first12=R |last13=Gralnek |first13=IM |last14=Jairath |first14=V |last15=Jensen |first15=D |last16=Lau |first16=J |last17=Lip |first17=GYH |last18=Loffroy |first18=R |last19=Maluf-Filho |first19=F |last20=Meltzer |first20=AC |last21=Reddy |first21=N |last22=Saltzman |first22=JR |last23=Marshall |first23=JK |last24=Bardou |first24=M |title=Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. |journal=Annals of Internal Medicine |volume=171 |issue=11 |pages=805–822 |date=22 October 2019 |doi=10.7326/M19-1795 |pmid=31634917|pmc=7233308 |doi-access=free }}</ref> [[Proton pump inhibitor]]s are often used.<ref name=Bey2019/> [[Tranexamic acid]] may also be useful.<ref name=Bey2019/> Procedures (such as [[Transjugular intrahepatic portosystemic shunt|TIPS]] for variceal bleeding) may be used. Recurrent or refractory bleeding may lead to need for [[surgery]], although this has become uncommon as a result of improved endoscopic and medical treatment.

<!-- History and epidemiology -->
Upper gastrointestinal bleeding affects around 50 to 150 people per 100,000 a year. It represents over 50% of cases of gastrointestinal bleeding.<ref name=Bey2019>{{cite journal |last1=Beyda |first1=R |last2=Johari |first2=D |title=Tranexamic acid for upper gastrointestinal bleeding. |journal=Academic Emergency Medicine |volume=26 |issue=10 |pages=1181–1182 |date=22 July 2019 |doi=10.1111/acem.13835 |pmid=31329328|doi-access=free }}</ref> A 1995 UK study found an estimated mortality risk of 11% in those admitted to hospital for gastrointestinal bleeding.<ref name=BSGE_guidelines_2002 />

==Signs and symptoms==
Persons with upper gastrointestinal bleeding often present with [[hematemesis]], [[coffee ground vomiting]], [[melena]], or [[hematochezia]] (maroon-coloured stool) if the hemorrhage is severe.  The presentation of bleeding depends on the amount and location of hemorrhage. A person with upper gastrointestinal bleeding may also present with complications of [[anemia]], including [[chest pain]], [[Syncope (medicine)|syncope]], [[fatigue (physical)|fatigue]] and [[shortness of breath]].{{citation needed|date=August 2020}}

The [[physical examination]] performed by the [[physician]] concentrates on the following things:{{citation needed|date=August 2020}}
* [[Vital signs]], in order to determine the severity of bleeding and the timing of intervention
* [[Abdomen|Abdominal]] and [[rectum|rectal]] examination, in order to determine possible causes of hemorrhage
* Assessment for [[portal hypertension]] and [[cirrhosis|stigmata of chronic liver disease]] in order to determine if the bleeding is from a variceal source.

Laboratory findings include [[anemia]], [[coagulopathy]], and an elevated [[BUN-to-creatinine ratio]].

==Causes==
[[Image:MALT 4.jpg|thumb|Gastric ulcer in [[Pylorus#Antrum|antrum]] of [[stomach]] with overlying clot.  Pathology was consistent with [[gastric lymphoma]].]]
A number of medications increase the risk of bleeding including [[NSAIDs]] and [[SSRIs]]. [[SSRIs]] double the rate of upper gastrointestinal bleeding.<ref>{{cite web |url=http://www.globalfamilydoctor.com/search/GFDSearch.asp?itemNum=12057&ContType=HDA |title=Are SSRIs associated with upper gastrointestinal bleeding in adults? |work=Global Family Doctor |access-date=2010-11-24 |archive-date=2011-07-11 |archive-url=https://web.archive.org/web/20110711101743/http://www.globalfamilydoctor.com/search/GFDSearch.asp?itemNum=12057&ContType=HDA }}</ref>

There are many causes for upper gastrointestinal hemorrhage.  Causes are usually anatomically divided into their location in the upper gastrointestinal tract.{{citation needed|date=August 2020}}

People are usually stratified into having either [[esophageal varices|variceal]] or non-variceal sources of upper gastrointestinal hemorrhage, as the two have different treatment algorithms and prognosis.{{citation needed|date=August 2020}}

The causes for upper gastrointestinal hemorrhage include the following:
* [[Esophagus|Esophageal]] causes (gastrorrhagia):
** [[Esophageal varices]]
** [[Esophagitis]]
** [[Esophageal cancer]]
** Esophageal ulcers
** [[Mallory-Weiss syndrome|Mallory-Weiss tear]]
* [[Stomach|Gastric]] causes:
** [[Gastric ulcer]]
** [[Gastric cancer]]
** [[Gastritis]]
** [[Gastric varices]]
** [[Gastric antral vascular ectasia]]
** [[Dieulafoy's lesion]]s
* [[Duodenum|Duodenal]] causes:
** [[Duodenal ulcer]]
** [[Vascular malformation]], including [[aorto-enteric fistulae]]. Fistulae are usually secondary to prior vascular surgery and usually occur at the proximal anastomosis at the third or fourth portion of the duodenum where it is retroperitoneal and near the aorta.<ref name="pmidpending">{{cite journal |author=Graber CJ |title=A Stitch in Time — A 64-year-old man with a history of coronary artery disease and peripheral vascular disease was admitted to the hospital with a several-month history of fevers, chills, and fatigue |journal=N Engl J Med |volume=357 |issue= 10|pages=1029–34 |year=2007|doi=10.1056/NEJMcps062601|pmid=17804848 |name-list-style=vanc |display-authors=1 |last2=Lauring |first2=Adam S. |last3=Chin-Hong |first3=Peter V.}}</ref><ref name="pmid12704326">{{cite journal |author=Sierra J, Kalangos A, Faidutti B, Christenson JT |title=Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy |journal=Cardiovascular Surgery (London, England) |volume=11 |issue=3 |pages=185–8 |year=2003 |pmid=12704326 |doi=10.1016/S0967-2109(03)00004-8|last2=Kalangos |last3=Faidutti |last4=Christenson }}</ref><ref name="pmid15279179">{{cite journal |author=Cendan JC, Thomas JB, Seeger JM |title=Twenty-one cases of aortoenteric fistula: lessons for the general surgeon |journal=The American Surgeon |volume=70 |issue=7 |pages=583–7; discussion 587 |year=2004 |pmid=15279179 |last2=Thomas Jb |last3=Seeger |doi=10.1177/000313480407000704 |s2cid=29517032 }}</ref>
** Hematobilia, or bleeding from the biliary tree
** [[Hemosuccus pancreaticus]], or bleeding from the [[pancreatic duct]]
** Severe [[superior mesenteric artery syndrome]]

==Diagnosis==
[[Image:Gastric ulcer 2.jpg|right|thumb|[[Esophagogastroduodenoscopy|Endoscopic]] image of small [[gastric ulcer]] with visible blood vessels]]
===Diagnostic testing===
The strongest predictors of an upper gastrointestinal bleed are black stool, age <50 years, and blood urea nitrogen/creatinine ratio 30 or more.<ref name=Witting/><ref name=Ernst1999/> The diagnosis of upper gastrointestinal bleeding is assumed when [[hematemesis]] (vomiting of blood) is observed.

A [[Nasogastric aspiration|nasogastric aspirate]] can help determine the location (source) of bleeding and help understand the best initial diagnostic and treatment plan. Nasogastric aspirate has a sensitivity of 42%, specificity 91%, [[negative predictive value]] 64%, positive predictive value 92% and overall accuracy of 66% in differentiating upper gastrointestinal bleeding from bleeding distal to the [[ligament of Treitz]].<ref name=Witting/> A positive aspirate is more helpful than a negative aspirate (If the aspirate is positive, an upper gastrointestinal bleed is likely; if the aspirate is negative, the source of a gastrointestinal bleed is probably, but not certainly, lower). A smaller study found a sensitivity of 79% and specificity of 55%, somewhat opposite results from Witting.<ref name=Cuellar/> The accuracy of the aspirate is improved by using the Gastroccult test.{{citation needed|date=August 2020}}

Determining whether blood is in gastric contents, either vomited or aspirated specimens, may be a challenge when determining the source of the hemorrhage. Slide tests are based on [[orthotolidine]] (Hematest reagent tablets and Bili-Labstix) or guaiac (Hemoccult and Gastroccult). There is some evidence that orthotolidine-based tests more sensitive than specific, the Hemoccult test's sensitivity reduced by the acidic environment; and the Gastroccult test be the most accurate.<ref>{{cite journal |author=Rosenthal P, Thompson J, Singh M |title=Detection of occult blood in gastric juice |journal=J. Clin. Gastroenterol. |volume=6 |issue=2 |pages=119–21 |year=1984 |pmid=6715849 |doi= 10.1097/00004836-198404000-00004|last2=Thompson |last3=Singh }}</ref> The sensitivity, specificity, positive predictive value, and negative predictive value have been reported as follows:<ref name="Cuellar" />

{| class="wikitable" style="text-align:center"
|+ Utvrđivanje prisutnosti krvi u želučanom aspiratu<ref name=Cuellar/>
! Nalaz !!Osjetljivost!! Specifičnoast !!Pozitivna prediktivna vrijednust<br />(prevalencija 39%)!! Negativna prediktivna vrijednost<br />(prevalence of 39%)
|-
! Gastroccult
| 95% || 82% || 77% || 96%
|-
! Procjena ljekara
| 79% || 55% || 53% || 20%
|}

Holman je koristio simulirane uzorke želuca i otkrio da Hemoccult test ima značajne probleme s nespecifičnošću i lažno pozitivnim rezultatima, dok je Gastroccult test bio vrlo tačane.<ref>{{cite journal |author=Holman JS, Shwed JA |title=Influence of sucralfate on the detection of occult blood in simulated gastric fluid by two screening tests |journal=Clin Pharm |volume=11 |issue=7 |pages=625–7 |year=1992 |pmid=1617913 |last2=Shwed }}</ref>
Holman je otkrio da je 120 sekundi nakon nanošenja razvijača, Hemoccult test bio pozitivan na "svim" kontrolnim uzorcima.

Sistem bodovanja nazvan [[Glasgow-Blatchford]] skala krvarenja otkrio je da je 16% osoba koje su se javile s krvarenjem iz gornjeg gastrointestinalnog trakta imalo Glasgow-Blatchford skalu "0", što se smatra niskim. Među tim osobama nije bilo smrtnih slučajeva ili potrebnih intervencija i mogle su biti efikasno liječene u ambulantnim uslovima..<ref>{{cite journal |vauthors=Stanley AJ, Ashley D, Dalton HR |title=Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation |journal=Lancet |volume=373 |issue=9657 |pages=42–7 |date=January 2009 |pmid=19091393 |doi=10.1016/S0140-6736(08)61769-9 |s2cid=1738579 |display-authors=etal}}</ref>  
<ref name="Ganymed ">{{cite web |url=http://www.ganfyd.org/index.php?title=Glasgow-Blatchford_score|archive-url=https://archive.today/20130112181646/http://www.ganfyd.org/index.php?title=Glasgow-Blatchford_score|url-status=usurped|archive-date=January 12, 2013|title=Glasgow-Blatchford bleeding score |access-date=2009-01-24}}</ref>

'''Rezultat je jednak "0" ako su prisutni svi sljedeći faktori:'''
# Nivo hemoglobina >12,9 g/dL (muškarci) ili >11,9 g/dL (žene)
# Sistolni krvni pritisak >109 mm Hg
# Puls <100/min
# Nivo uree u krvi <18,2 mg/dL
# Nema melene ili sinkope
# Nema prošlih ili sadašnjih bolesti jetre ili srčane insuficijencije

===Bayesian calculation===
The predictive values cited are based on the prevalences of upper gastrointestinal bleeding in the corresponding studies. A  clinical calculator can be used to generate predictive values for other prevalences.{{citation needed|date=August 2020}}

== Treatment ==
The initial focus is on [[resuscitation]] beginning with airway management and fluid resuscitation using either intravenous fluids and or blood.<ref name=Overall2011>{{cite journal|last=Jairath|first=V|author2=Barkun, AN |title=The overall approach to the management of upper gastrointestinal bleeding.|journal=Gastrointestinal Endoscopy Clinics of North America|date=October 2011|volume=21|issue=4|pages=657–70|pmid=21944416|doi=10.1016/j.giec.2011.07.001}}</ref> A number of medications may improve outcomes depending on the source of the bleeding.<ref name=Overall2011/> [[Proton pump inhibitor]] medications are often given in the emergent setting before an endoscopy and may reduce the need for an endoscopic haemotstatic treatment.<ref name=":0">{{Cite journal |last1=Kanno |first1=Takeshi |last2=Yuan |first2=Yuhong |last3=Tse |first3=Frances |last4=Howden |first4=Colin W. |last5=Moayyedi |first5=Paul |last6=Leontiadis |first6=Grigorios I. |date=2022-01-07 |title=Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding |url= |journal=The Cochrane Database of Systematic Reviews |volume=1 |issue=1 |article-number=CD005415 |doi=10.1002/14651858.CD005415.pub4 |issn=1469-493X |pmc=8741303 |pmid=34995368}}</ref> Proton pump inhibitors decrease gastric acid production.<ref name=":0" /> There is insufficient evidence to determine if proton pump inhibitors decrease death rates, re-bleeding events, or the need for surgical interventions.<ref name=":0" /> After the initial resuscitation has been completed, treatment is instigated to limit the likelihood of re-bleeds and correct any anemia that the bleeding may have caused. Those with a [[Glasgow Blatchford score]] less than 2 may not require admission to hospital.<ref name=Bark2019>{{cite journal |last1=Barkun |first1=Alan N. |last2=Almadi |first2=Majid |last3=Kuipers |first3=Ernst J. |last4=Laine |first4=Loren |last5=Sung |first5=Joseph |last6=Tse |first6=Frances |last7=Leontiadis |first7=Grigorios I. |last8=Abraham |first8=Neena S. |last9=Calvet |first9=Xavier |last10=Chan |first10=Francis K.L. |last11=Douketis |first11=James |last12=Enns |first12=Robert |last13=Gralnek |first13=Ian M. |last14=Jairath |first14=Vipul |last15=Jensen |first15=Dennis |last16=Lau |first16=James |last17=Lip |first17=Gregory Y.H. |last18=Loffroy |first18=Romaric |last19=Maluf-Filho |first19=Fauze |last20=Meltzer |first20=Andrew C. |last21=Reddy |first21=Nageshwar |last22=Saltzman |first22=John R. |last23=Marshall |first23=John K. |last24=Bardou |first24=Marc |title=Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group |journal=Annals of Internal Medicine |volume=171 |issue=11 |pages=805–822 |date=22 October 2019 |doi=10.7326/M19-1795|pmid=31634917 |pmc=7233308 |doi-access=free }}</ref>

===Peptic ulcers===
Based on evidence from people with other health problems [[Crystalloid solution|crystalloid]] and [[Volume expander#Colloids|colloids]] are believed to be equivalent for peptic ulcer bleeding.<ref name=Overall2011/> In people with a confirmed peptic ulcer, proton pump inhibitors do not reduce death rates, later bleeding events, or need for surgery.<ref name=Ser2019>{{cite journal |last1=Serpico |first1=M |last2=Riscinti |first2=M |title=Proton Pump Inhibitors for Acute Upper Gastrointestinal Bleeding. |journal=Academic Emergency Medicine |date=6 December 2019 |volume=27 |issue=4 |pages=336–338 |doi=10.1111/acem.13899 |pmid=31808973|doi-access=free }}</ref> They may decrease signs of bleeding at endoscopy however.<ref name=Ser2019/> In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance.<ref name=":0" /> [[Tranexamic acid]] might be effective to reduce mortality, but the evidence for this is weak.<ref name=Overall2011/><ref>{{Cite journal|last1=Bennett|first1=Cathy|last2=Klingenberg|first2=Sarah Louise|last3=Langholz|first3=Ebbe|last4=Gluud|first4=Lise Lotte|date=2014-11-21|title=Tranexamic acid for upper gastrointestinal bleeding|journal=The Cochrane Database of Systematic Reviews|volume=2014 |issue=11|article-number=CD006640|doi=10.1002/14651858.CD006640.pub3|issn=1469-493X|pmid=25414987|pmc=6599825}}</ref> But the evidence is promising.<ref>{{cite journal|last=Gluud|first=LL|author2=Klingenberg, SL, Langholz, SE|title=Systematic review: tranexamic acid for upper gastrointestinal bleeding|journal=Alimentary Pharmacology & Therapeutics|date=May 2008|volume=27|issue=9|pages=752–8|pmid=18248659|doi=10.1111/j.1365-2036.2008.03638.x|s2cid=24594884|doi-access=free}}</ref> [[Somatostatin]] and [[octreotide]] while recommended for variceal bleeding have not been found to be of general use for non-variceal bleeds.<ref name=Overall2011/>

===Variceal bleeding===
For initial fluid replacement colloids or [[albumin]] is preferred in people with cirrhosis.<ref name=Overall2011/> Medications typically includes [[octreotide]] or if not available [[vasopressin]] and [[nitroglycerin]] to reduce portal pressures.<ref name=N2010>{{cite journal|last=Cat|first=TB|author2=Liu-DeRyke, X |title=Medical management of variceal hemorrhage|journal=Critical Care Nursing Clinics of North America|date=September 2010|volume=22|issue=3|pages=381–93|pmid=20691388|doi=10.1016/j.ccell.2010.02.004}}</ref> This is typically in addition to [[Therapeutic endoscopy|endoscopic banding]] or [[sclerotherapy]] for the varices.<ref name=N2010/> If this is sufficient then [[beta blockers]] and [[nitrates]] may be used for the prevention of re-bleeding.<ref name=N2010/> If bleeding continues then balloon tamponade with a [[Sengstaken-Blakemore tube]] or [[Minnesota tube]] may be used in an attempt to mechanically compress the varices.<ref name=N2010/> This may then be followed by a [[transjugular intrahepatic portosystemic shunt]].<ref name=N2010/>

===Blood products===
If large amounts of pack red blood cells are used additional [[platelets]] and [[fresh frozen plasma]] should be administered to prevent [[coagulopathy|coagulopathies]].<ref name=Overall2011/> Some evidence supports holding off on blood transfusions in those who have a [[hemoglobin]] greater than 7 to 8 g/dL and only moderate bleeding.<ref name=Overall2011/><ref name="transfusions">{{cite journal|doi=10.1056/NEJMoa1211801|pmid=23281973|title=Transfusion Strategies for Acute Upper Gastrointestinal Bleeding|year=2013|last1=Villanueva|first1=Càndid|last2=Colomo|first2=Alan|last3=Bosch|first3=Alba|last4=Concepción|first4=Mar|last5=Hernandez-Gea|first5=Virginia|last6=Aracil|first6=Carles|last7=Graupera|first7=Isabel|last8=Poca|first8=María|last9=Alvarez-Urturi|first9=Cristina|last10=Gordillo|first10=Jordi|last11=Guarner-Argente|first11=Carlos|last12=Santaló|first12=Miquel|last13=Muñiz|first13=Eduardo|last14=Guarner|first14=Carlos|journal=New England Journal of Medicine|volume=368|pages=11–21|issue=1|display-authors=8|doi-access=free}}</ref> If the INR is greater than 1.5 to 1.8 correction with fresh frozen plasma, [[prothrombin complex]] may decrease mortality.<ref name=Overall2011/>

===Procedures===
[[Image:GU with clip.jpg|right|thumb|The above ulcer seen after endoscopic clipping]]
Upper endoscopy within 24&nbsp;hours is the recommended treatment.<ref name="Overall2011" /><ref name=":1">{{Cite journal |last1=Adão |first1=Diego |last2=Gois |first2=Aecio FT |last3=Pacheco |first3=Rafael L |last4=Pimentel |first4=Carolina FMG |last5=Riera |first5=Rachel |date=2023-02-01 |editor-last=Cochrane Gut Group |title=Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage |journal=Cochrane Database of Systematic Reviews |language=en |volume=2023 |issue=2 |article-number=CD013176 |doi=10.1002/14651858.CD013176.pub2 |pmc=9891197 |pmid=36723439}}</ref> The benefits versus risks of placing a [[nasogastric tube]] in those with upper gastrointestinal bleeding are not well known.<ref name=Overall2011/>  [[Prokinetic agent|Prokinetic agents]] to empty the stomach such as [[erythromycin]] before endoscopy can decrease the amount of blood in the stomach and thus improve the operators view.<ref name=Overall2011/> This erythromycin treatment may lead to a small decrease in the need for a blood transfusion, but the overall balance of how effective erythromycin is compared to potential risks is not clear.<ref name=Overall2011/><ref name=":1" /> Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found.<ref name=Overall2011/> It is also recommended that people with high risk signs are kept in hospital for at least 72&nbsp;hours.<ref name=Overall2011/>
Blood transfusions are not generally recommended to correct anemia, but blood transfusions are recommended if the person is not stable (cardiovascular system instability).<ref name="transfusions"/> Oral iron can be used, but this can lead to problems with compliance, tolerance, darkening stools which may mask evidence of rebleeding and tends to be slow, especially if used in conjunction with proton pump inhibitors. [[Parenteral]] Iron is increasingly used in these cases to improve patient outcomes and void blood usage.{{citation needed|date=August 2020}}

==Prognosis==
Depending on its severity, upper gastrointestinal bleeding may carry an estimated mortality risk of 11%.<ref name=BSGE_guidelines_2002>{{cite journal|last=British Society of Gastroenterology Endoscopy Committee|title=Non-variceal upper gastrointestinal haemorrhage: guidelines|journal=Gut|date=October 2002|volume=51 |issue=Suppl 4 |pages=iv1–6|pmid=12208839|url= |pmc=1867732|doi=10.1136/gut.51.suppl_4.iv1}}</ref> However, survival has improved to about 2 percent, likely as a result of improvements in medical therapy and endoscopic control of bleeding.<ref name=Cai_GIendo>{{cite journal |last1=Cai |first1=Jennifer X. |last2=Saltzman |first2=John R. |title=Initial Assessment, Risk Stratification, and Early Management of Acute Nonvariceal Upper Gastrointestinal Hemorrhage |journal=Gastrointestinal Endoscopy Clinics of North America |date=July 2018 |volume=28 |issue=3 |pages=261–275 |doi=10.1016/j.giec.2018.02.001 |pmid=29933774|s2cid=49377957 }}</ref>

==Epidemiology==
About 75% of people presenting to the [[emergency department]] with gastrointestinal bleeding have an upper source.<ref name=Ernst1999>{{cite journal |author=Ernst AA, Haynes ML, Nick TG, Weiss SJ |title=Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding |journal=Am J Emerg Med |volume=17 |issue=1 |pages=70–2 |year=1999 |pmid=9928705 |doi=10.1016/S0735-6757(99)90021-9 |last2=Haynes |last3=Nick |last4=Weiss }}</ref> The diagnosis is easier when the people have [[hematemesis]]. In the absence of hematemesis, 40% to 50% of people in the emergency department with gastrointestinal bleeding have an upper source.<ref name=Witting>{{cite journal |author=Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M |title=ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis |journal=Am J Emerg Med |volume=24 |issue=3 |pages=280–5 |year=2006 |pmid=16635697 |doi=10.1016/j.ajem.2005.11.005 |last2=Magder |last3=Heins |last4=Mattu |last5=Granja |last6=Baumgarten }}</ref><ref name=Cuellar>{{cite journal |author=Cuellar RE |title=Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate |journal=Archives of Internal Medicine |volume=150 |issue=7 |pages=1381–4 |year=1990 |pmid=2196022 |doi= 10.1001/archinte.150.7.1381|name-list-style=vanc|author2=Gavaler JS |author3=Alexander JA |display-authors=3 |last4=Brouillette |first4=DE |last5=Chien |first5=MC |last6=Yoo |first6=YK |last7=Rabinovitz |first7=M |last8=Stone |first8=BG |last9=Van Thiel |first9=DH}}</ref><ref>{{cite journal |author=Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M |title=Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis |journal=Ann Emerg Med |volume=43 |issue=4 |pages=525–32 |year=2004 |pmid=15039700 |doi= 10.1016/j.annemergmed.2003.09.002|last2=Magder |last3=Heins |last4=Mattu |last5=Granja |last6=Baumgarten }}</ref>

==See also==
* [[Lower gastrointestinal bleeding]]
* [[Forrest classification]]
* [[Rockall score]]

==References==
{{Reflist}}

== External links ==
* [http://www.patient.co.uk/showdoc/40000851/ Patient.uk] {{Webarchive|url=https://web.archive.org/web/20210827173019/https://patient.info/doctor/upper-gastrointestinal-bleeding-includes-rockall-score |date=2021-08-27 }}
{{Medical resources
|  DiseasesDB      = 19317
|  ICD10           = {{ICD10|K|92|2|k|90}}
|  ICD9            = {{ICD9|578.9}}
|  MedlinePlus     = 003133
|  eMedicineSubj   = med
|  eMedicineTopic  = 3565
|  MeshID          = D006471
}}

{{Gastroenterology}}

{{DEFAULTSORT:Upper Gastrointestinal Bleeding}}
[[Category:Bleeding]]
[[Category:Gastrointestinal tract disorders]]
[[Category:Medical emergencies]]